UTILITIES TRANSFER FORM
(A current Driver’s License and Social Security Number is required for all applicants)
The City of Troy is committed to ensuring that your information is secure. In order to prevent unauthorized access or disclosure,
we have put in place suitable physical, electronic, and managerial procedures to safeguard and secure the information we collect.
Account Information
Name: Date:__________________________
Birth Date:________________ Drivers License #/Other ID:________________ Social Security #/Tax ID:
Phone Number: _____________________________ Email Address:_________________________________________
Business Name (if applicable):_______________________________________________________________________
Current Service Address:
Current Service Account Number:_______________________ Current Service Deactivation Date:_________________
New Service Address:
Landlord’s Name if Renting:________________________ New Service Activation Date:_________________________
New Billing Address:_______________________________________________________________________________
Emergency Contact: Emergency Phone #:
________________________________________________________________________________________________
**Please be aware of the following in regard to discontinuance of service when applicable: **
Pursuant to Sec. 13-10 of the City of Troy Code of Ordinances, requests for disconnection must be submitted in writing and are
not accepted over the phone. If an account holder fails to notify the City of disconnect, they will continue to be responsible for
all charges until service is placed back into the owner’s name or a new occupant requests service.
________________________________________________________________________________________________
Applicant agrees to abide by all City Ordinances & Rules. Service is exclusively for the Applicant. Bills are due and payable in a
manner & time indicated on the bill. Service may be denied without notice for delinquency in payment or violation of law and/or
City ordinances, rules or regulations. Applicant does hereby swear or affirm that all information supplied on this application is
complete and accurate.
Applicant Signature Date
THIS SPACE RESERVED FOR OFFICE USE ONLY
Application Reviewed By:______________________ Application Received By: £ Office £ Mail £ Fax £ Other_________
301 Charles W. Meeks Avenue · PO Box 549 · Troy, Alabama 36081 | Phone: 334.566.0177 | Fax: 334.808.7404
Email: customerservice@troyal.gov | www.troyal.gov
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