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INFORMATION UPDATE
FOR CURRENT ACCOUNT
This form is for current customers only who have an active account.
Please include applicable legal documents such as marriage license, death certificate,
etc. and two forms of identification.
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Current Name on Account___________________________________________________________
Service Address _____________________________________________________________________
Billing Address, if different ____________________________________________________________
I hereby request that the name on my account be changed to:
Legal Name: First ___________________ MI__________ Last______________________________
The reason for my request is: _________________________________________________________
Home Phone_____________________ Work Phone _______________ Cell _________________
SS# _____________________ DL# __________________ State_____ Date of Birth ____________
Spouse or Co-Occupant Legal Name: First ____________MI ____ Last ___________________
Their Work Phone ____________Their Cell Phone______________ Their SS# _______________
Please list a password for your account ______________________________________________
and a reminder, in case you forget your password: ___________________________________
Signature _____________________________________ Date _________________________
If you cannot submit this form in person we require that this form be notarized and submitted
with very clear legible copies of two forms of identification one of which must be a photo I.D.
and related legal documents. We will not change the name until documents are received and
are legible.
NOTARY STAMP OR SEAL Notary Public___________________________________________
County of ______________________ State of ______________
Signed before me this___________ day of ________________
My commission expires ________________________________
