TOWN OF WINNSBORO
THIRD-PARTY NOTIFICATION FORM
(Please Type or Print All Information)
Name Account Number
Social Security Number ____________________
Work Phone Home Phone Cell Phone
Account Address
The Town of Winnsboro is committed to a third-party notification system for its electric/natural gas customers. The intent of this program is to offer our customers the opportunity to have a third party notified in the event of disconnection of electric and natural gas service due to non-payment of bills.
Customers wishing to take advantage of this system must complete this form in its entirety and return it to P.O. Box 209, Winnsboro, SC 29180. By submitting this form, the customer authorizes the Town of Winnsboro to release his or her utility account information to any or all of the parties listed by the customer below. The customer also assumes the responsibility to notify the Town of Winnsboro of any changes to the contact information listed on this form.
In the event that service for the above utility account is scheduled for disconnection, the town will call the telephone numbers for the customer and the third party listed on the Third-Party Notification Form to notify them of the utility’s intention to disconnect the customer’s service.
This form relates to electric and natural gas service and the town reserves the right to disconnect any other service for which payment is past due.
In the event that the town attempts to notify the account holder (customer) and the authorized third party listed below and is unable to reach any or all parties, the town will continue with service disconnection as scheduled.
This form must be renewed annually by October 15 to ensure service continuity.
Authorized Third Party:
Name
Work Phone Home Phone Cell Phone
Street Address
City, State, Zip
Customer Authorization:
I, , understand and agree to the terms listed herein and authorize the Town of Winnsboro to notify the above authorized third party as to the status of payment or non-payment of my Town of Winnsboro utilities account. 1 further understand that failure of the Town of Winnsboro, upon reasonable attempt described here, to notify me or the authorized third party will not preclude the Town of Winnsboro from disconnecting my electric service.
Customer Signature: Date:
Customer Printed Name
Third Party Signature: Date:
Third Party Printed Name
Date:
(Ord. 11-20-06-A, passed 11-20-2006)