C&L Electric Cooperative

Name to change to*

Current name to be changed*

Account Number*

Billing Address*

Social Security Number *

DL #*

Phone Number*

Email Address*

Account name change reason*

Divorce or Legal Separation - Legal papers required

Death of a member - Death Certificate required

Legal Guardianship or Executor of Estate - Legal papers required

Spouse/Roommate adding or moving out

Please Specify

Spouse/Roommate*

Date*

Witness*

Upload documents that are required

(pdf, docx, jpg, jpeg, png)

Upload documents that are required

(pdf, docx, jpg, jpeg, png)

I do hereby request the account number listed under the name listed to be changed for the following reason or reasons. By changing information on the account, I understand it does not release responsibility of the bills debt. I also understand that proper documentation must accompany this form before any changes may occur. I also understand there may be additional charges, like a new membership number or deposit due before the account is changed.

By submitting this Application online, the Applicant agrees to the use of electronic signatures.

The acceptance of this application by the Cooperative shall constitute an agreement between the Applicant and the Cooperative, and the contract for electric service shall continue in force from the date service is made available by the Cooperative to the Applicant, and thereafter until cancelled by notice given by either party to the other. Everything the AppIicant has stated in this application is correct to the best of their knowledge. The Applicant understands that the Cooperative will retain this Application whether it is approved. The Cooperative is authorized to check the Applicant's credit and to answer questions about the Cooperative's credit experience with the Applicant.

Applicant's Signature
(Type your name)*