Authorization Agreement For Automatic Transfer

This form allows property owners to request that billing responsibility automatically transfer back to their name whenever a tenant requests a disconnection of electric service.

Please fill in each required field* and press SUBMIT. You will receive a confirmation message when complete.

Claverack Rural Electric Cooperative, Inc. offers this electronic form to members of the cooperative for their convenience. A hard copy of this form is available for completion at our main office or can be requested by mail.

Owner's Name:

Owner's Phone Number

Please list all 911 property addresses to be covered under this agreement.

I authorize automatic transfer as follows: As the owner of the properties listed above, I authorize Claverack REC to automatically transfer billing responsibility for electric service into my name when a tenant requests disconnection of same. I understand that this does not include disconnection for non-payment situations. This agreement will remain in effect until I am no longer the property owner. I will notify the cooperative at least 30 days in advance if my ownership of any property ends.

Please read

Authorization agreement details above.

Electronic Signature:

Type your name as you would sign it.

FOR OFFICE USE ONLY

Owner's Capital Credit Number:

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32750 Route 6, Wysox PA 18854

Phone: 570-265-2167

Toll-Free: 800-326-9799

Fax: 570-265-6019

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41°45'34.0"N 76°21'46.0"W