Request for Disconnection

2. First Name

3. Last Name

5. Account Number

7. Service Address

9. City

10. State

12. Zip

13. Phone Number

15. Forwarding Address

17. Address2

19. City

20. State

21. Zip

23. Requested Disconnection Date*

    (No Same-Day Disconnections)

24. Confirmation Email Address*

    An email will be sent to this address to confirm the details of your disconnection.

26. Please Note:
    Disconnections are completed Monday - Friday, as early as 7 a.m., no weekends or holidays. Requested disconnection date should be no sooner than the following business day. Please call 972.874.6010 if you are submitting your request by any other means than in-person and have not obtained a confirmation from the Town of Flower Mound.

    Disconnections are completed Monday - Friday, as early as 7 a.m., no weekends or holidays. Requested disconnection date should be no sooner than the following business day. Please call 972.874.6010 if you are submitting your request by any other means than in-person and have not obtained a confirmation from the Town of Flower Mound.

28. Person Requesting Disconnect

    If different than above.

29. Any Additional Information

Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field