** Contains Controlled Unclassified Information When Completed **
OMB # 1076-0021
Expires: 11/2022
________________ AGENCY
Rev. 11/2019
Name: ______________________________________
First Middle Last
________ Social Security #_____________________
Billing Address: ________________________________________Telephone: (HM) _
______________________________________________________ ____________________
Service Address:___________________________________________________________________________
Legal Description (lot/block, etc.):____________________________________________________________
Type of Service Requested: Residential ____________ Commercial _____________
Previous Customer? Yes _____ No _____
If yes, do you or spouse owe a balance? Yes _____ No _____
Date Service Desired: ________________________ Existing? ____ New Service? _____
Customer Signature: __________________________________________________ Date: _______________
Do Not Complete This Section - For Agency Use Only
Check for Security Light: Initial _________
Route # ________ Stop # ________ Account # __________________ New Cust # ________________
Meter #___________ Amps _________ Volts __________ Phase ______ S/W/O #____________________
Read-out Customer #_____________ Name___________________________________
Additional Information: _____________________________________________________________________
Information Received By:______________________________________________ Date: _______________
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Page 2
Pursuant to the Debt Collection Improvement Act of 1996 (Public Law 104-134), you are required to
furnish our office your taxpayer identification number (TIN). If you do not have a business TIN, then
your Social Security Number is your TIN.
Paperwork Reduction Act Notice - This information is being collected as required under the Debt Collection
Improvement Act of 1996 (DCIA) from individuals and organizations doing business with the government.
Public reporting burden for this form is estimated to average 12 minutes per response. Direct comments
regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer,
Bureau of Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240. Note: comments, names and
addresses of commentators are available for public review during regular business hours. If you wish us to
withhold this information you must state this prominently at the beginning of your comment. We will honor
your request to the extent allowable by law. A federal agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number.
The number and expiration date are displayed in the upper right corner of the form.
Privacy Act Statement - Authority: 25 U.S.C 385c; 25 CFR Part 175 and Public Law 104-134 (110 Stat.
1321-364). Purpose: Information collected will be used establish and service electrical power/service
accounts. Routine Uses: Bureau of Indian Affairs will use information collected for billing, collections,
payment application and debt management actions for the recipient of the electric power/service. This
information may be disclosed to the U.S. Department of Justice or in a proceeding before a court or adjudicative
body; Federal, state, local, or foreign law enforcement agency; Congress; U.S. Department of Treasury to effect
payment; Federal agency for collecting a debt; and other Federal agencies to detect and eliminate fraud. The
information may also be used for filing tax documents with the Internal Revenue Service (IRS) as required by
law pursuant to the routine uses identified in the Privacy Act system of record notice Electrical Utility
Management System, BIA-26. Disclosure: Disclosure is voluntary, but failure to provide information will
prevent you from receiving electrical power/service.