Release of Utility Historical Information

Customer Information

* required information

Company Name: *

Contact First Name: *

Contact Last Name: *

E-mail Address: * name@domain.com Confirm Email Address*

Phone Number: * 555.123.4567

Fax Number: 555.123.4567

Service Address

* required information

Account Number: * (The ten-digit number located on the Ameren bill for this service location.)

Address: *

Address:

City: *

State: *

ZIP Code: *

Add Another Account and Address

Second Account Information

Account Number: * (The ten-digit number located on the Ameren bill for this service location.)

Address: *

Address:

City: *

State: *

ZIP Code: *

Third Party

A Third Party is a person or company that the customer has formally authorized to receive their historical data.

* required information

Company Name: *

Contact First Name: *

Contact Last Name: *

Address: *

Address:

City: *

State: *

ZIP Code: *

E-mail Address: * name@domain.com Confirm Email Address*

Phone Number: * 555.123.4567

Fax Number: 555.123.4567

Please also send me a copy of this historical data report in addition to the Third Party specified above.

I have read and agree to the below *

I affirm that I am the person who prepared this form, or that I have prepared and submitted this form as the duly authorized executor, guardian, authorized officer, or agent of such named person, and that I acknowledge that I have read and understood all of the questions in this application and that all of the information submitted in this application is true and correct to the best of my knowledge, and that all responses to the questions are full and complete, omitting no material information.

Any person who submits false or inaccurate information as part of this form may be subject to fines and/or punishment pursuant to applicable federal and/or state laws and regulations.

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Residential

Business

Our Company

Customer Information

Service Address

Second Account Information

Third Party