Utility Account Update Utility Account Update Please complete and review the Applicant's Statement and Acknowledgements. ONLY use this form for legal name change, additional name to account, mailing address if different from service address, or phone number or email change. IF person responsible for paying bill has changed, you MUST complete Application to Disconnect Services and the new party MUST complete Application to Start Services. Current Account Information Account Number: * Number listed on your bill without periods. Today's Date: * Current Account Name: * Name as listed on account (responsible party(ies). Service Address: * Service Address: Service Address: Service Address: City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Primary Phone Number: * Secondary Phone Number: Email: * New Account Information: New Account Name if different: This does not assign a new party responsible for the bill. Mailing address if different from service address: Mailing address if different from service address: Mailing address if different from service address: Mailing address if different from service address: City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Primary Phone Number if different: Secondary Phone Number if different: Email if different: Reason for change: * Applicant's Statement and Acknowledgements By requesting the City of Breese to make updates to account information, it does not warrant a different party responsible for the bill. It remains the same account holder's responsibility to pay all bills on or before the 25th of each month and to be responsible for all utilities consumed at the above address. You further agree that if the utility bill is not paid by the 10th of the month following the due date, the city is authorized to discontinue such service(s) with a final notice. The City of Breese reserves the right to require a signed Utility Account Update for the changes requested to be submitted in person along with a form of ID. Customer will be subject to current rates, rules and regulations as approved by the City of Breese. You must notify the city when you vacate to end service(s) at the address you are vacating. Otherwise, you could be liable for any charges incurred after you have moved. Application for service(s) shall be made in the legal name of the party obligated to pay for service(s). Terms of Acceptance * I understand that checking this box constitutes a legal signature confirming I acknowledge and agree to the above Statement and Acknowledgements. Requested by: * Requested by: First Name First Name Last Name Last Name Date: * Submit If you are human, leave this field blank. Skip back to main navigation
