Electric Service Application

OMB # 1076-0021

Expires: XX/XX/XXXX

UNITED STATES DEPARTMENT OF THE INTERIOR

BUREAU OF INDIAN AFFAIRS

________________ AGENCY

ELECTRICAL SERVICE APPLICATION

Customer Signer’s

Name: ______________________________________________ Social Security#_____________________

Last First Middle

Date of Birth: ______________________

Billing

Address: ______________________________________________Telephone: (HM) ____________________

______________________________________________________ (WK) ____________________

Next of Kin: (Not living with you) _____________________________Relationship:________________________

Address: ______________________________________________Phone: ____________________________

Legal Description (lot/block, ect.):_____________________________________________________________

________________________________________________________________________________________

Type of Service Required: Residential ____________ Commercial _____________

Prior BIA Customer? Yes _____ No _____

If yes, do you or spouse owe a balance? Yes _____ No _____

Date Service Wanted By: ________________________

Existing or New Service? ________________________

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Check for Security Light: Initial _________

Route # ________ Stop # ________ Account # __________________ New Cust # ________________

Meter #___________ Amps _________ Volts __________ Phase ______ S/W/O #____________________

Read-out Customer #_____________ Name___________________________________

Additional Information:______________________________________________________________________________

________________________________________________________________________________________

Customer Signature: __________________________________________________Date: _______________

Information Received By: _____________________________________________ Date: _______________

THIS INFORMATION IS BEING COLLECTED TO DETERMINE THE CONSUMERS ELECTRICAL NEEDS, AND WILL BE USED TO DETERMINE CONSUMPTION COSTS. RESPONSE TO THIS REQUEST IS REQUIRED TO OBTAIN A BENEFIT IN ACCORDANCE WITH 25 CFR 175.

Pursuant to the Debt Collection Improvement Act of 1996 (Public Law 104-134), you are required to furnish our office your taxpayer identification number (TIN). If you do not have a business TIN, then your Social Security Number is your TIN.

Paperwork Reduction Act Statement: This information being collected is required under the Debt Collection Improvement Act of 1996 (DCIA) from individuals and businesses doing business with the government. Public reporting burden for this form is estimated to average 30 minutes per response. Direct comments regarding the burden estimate or any other aspect of this form to Attn: Information Collection Clearance Officer – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240. Note: comments, names and addresses of commentators are available for public review during regular business hours. If you wish us to withhold this information you must state this prominently at the beginning of your comment. While you can ask us in your comment to withhold your personal identifying information from public review, we cannot guarantee that we will be able to do so. A federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The number and expiration date are displayed in the upper right corner of the form.

Privacy Act Statement (5 U.S.C. 552 (a)): The Privacy Act, as amended, authorizes the collection of this information. The primary use of this information is to identify recipient(s) of the electric power services rendered and the person(s) responsible for monetary charges (service bill) associated with providing the desired benefit. Disclosure of information may be to: U.S. Department of Justice or in a proceeding before a court or adjudicative body; Federal, state, local, or foreign law enforcement agency; Members of Congress; Department of Treasury to effect payment; Federal agency for collecting a debt; and other Federal agencies to detect and eliminate fraud. BIA maintains files containing personally identifiable information in accordance with the Privacy Act system of record notice Electrical Utility Management System, BIA-26.