Required fields are marked with asterisks (*)

Account Closure — Tenant

The information collected on this form will be used by the City of Belleville to establish and maintain a service connection and for billing and collection purposes.

Registered Property Owner First and Last Name:

Service Address

Street Number and Name:

Unit Number (if applicable):

Account Number:

Client Code:

Effective Date:

Customer Information

Business Name:

Common Name:

If you have a refund on account would you like it processed via direct deposit?

Yes

Mailing Address

Street Number and Name:

Unit number (if applicable):

City:

Province:

Postal Code:

Email Address:

Telephone:

Fax Number:

Signator

First and Last Name:

Position:

First and Last Name: