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2. 
4. Request for Disclosure
6. 1. I request and authorize the City of Burleson to disclose information in my utility account record

   including utility usage, amount due (current and past due), due dates, initiation and/or termination dates, disconnect dates and billing and payment history.

8. Account information
10. Account number (including the dash)*
12. Service Address*
14. Phone number*
16. By electronically signing this form, I attest that I am the authorized account holder of the above account.
18. Signature
19. Date
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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field