Request for Disconnect of Services

Complete the online form below.

P O BOX 110
17218 Hwy. 72 W
Athens, AL 35611

* required fields
Note: We suggest using Chrome browser.

Today's Date:

Date of Disconnect:

Address of Service of Disconnect*:

Customer #:

Forwarding Address for Final Bill*:

Driver's License Number of Account Holder:

Social Security of Account Holder (last 4 digits):

By accepting below, the customer understands there will be a final bill generated which is for service from the last billing to the date of disconnection of service.
LCWSA reserves the right to turn over any unpaid past due balance to a collection agency. If the balance is not paid to the agency or to LCWSA, this balance will be reflected on your credit report.

The connection fee paid at the time of your request for service was a non-refundable fee.

I accept: