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Request to rescind Request for Disclosure

2. 
4. Request to rescind Request for Disclosure
6. By checking the box below, I request the City of Burleson remove my previous authorization for disclosure of information related to the account referenced below.

   1. I rescind my previous request for account disclosure.
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

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