NAME CHANGE FORM new Jan 22

CITY OF LACY LAKEVIEW

AUTHORIZATION FOR WATER BILL- WATER DEPOSIT NAME CHANGE
*IMPORTANT: PLEASE BE ADVISED THAT SUBMITTING THIS FORM INCLUDES RELINQUISHING THE DEPOSIT YOU HAVE PAID ON THE ACCOUNT. IF YOU WISH TO KEEP THE DEPOSIT, THE NEW RESIDENT WILL HAVE TO PUT A NEW DEPOSIT DOWN TO OPEN A UTILITY ACCOUNT *
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PRESENT NAME ON WATER BILL/WATER DEPOSIT

First NameLast Name
NAME DESIRED TO APPEAR ON WATER BILL/DEPOSIT

First NameLast Name
If you would like the present name and additional name on the account, please include both names in the box below. This would authorize both residents to make changes to the account.
PLEASE WRITE HOW YOU WOULD LIKE THE NAME/NAMES TO APPEAR ON THE WATER BILL.
IF YOU WOULD LIKE MULTIPLE NAMES ON THE ACCOUNT PLEASE WRITE ABOVE HOW YOU WOULD LIKE IT TO REFLECT ON THE BILL
NEW RESIDENT'S SOCIAL SECURITY NUMBER:
NEW RESIDENT'S PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
DEATH CERTIFICATE:

DEATH CERTIFICATE IS ONLY REQUIRED IF THE PRIMARY ACCOUNT HOLDER IS DECEASED.
Cancelof
IDENTIFICATION CARD CURRENT RESIDENT

Cancelof
IDENTIFICATION CARD OF NEW PERSON ADDED TO THE ACCOUNT

Cancelof
PROOF OF PURCHASE/LEASE/RENTAL AGREEMENT:

ANY PERSON ADDED TO THE ACCOUNT WILL HAVE TO HAVE THEIR NAME ON THE LEASE/RENTAL AGREEMENT/PROOF OF PURCHASE IN ORDER FOR THE NAME TO BE UPDATED
Cancelof
I CERTIFY THAT: (CHECK ONE)

Other
Email
example@example.com
Signature
Date

MonthDayYear
Date
COMPLETION STATUS
Should be Empty:

CITY OF LACY LAKEVIEW