Identity Verification Form (Page 2 of 2) in pdf

Identity Verification Form Page 2

Identity Verification Form

Upon request by Piedmont Natural Gas, this form must be completed to validate an individual’s

identity in connection with establishing or maintaining a utility account with Piedmont Natural

Gas.

Section I

I, __________________________, the undersigned, do hereby state and declare the following:

(Printed Name)

This affidavit concerns utility service at the following service location:

Address: ____________________________________________________________________

City: _____________________________ State: ________________ Zip: _________________

Section II

Section III of this form was completed by a notary at the following:

Notary Business Name: _________________________________________________________

Notary Business Address: _______________________________________________________

City: _____________________________ State: ________________ Zip: _________________

I understand that knowingly making any false or fraudulent statement or representation may

constitute a violation of federal, state, or local criminal statutes, and may result in imposition of a

fine or imprisonment or both.

Applicant

Signature: ________________________________ Date: __________________

Section III

State: _________________ County _______________________

I do hereby certify that ___________________________ personally appeared before me this

day and is known to me (or satisfactorily proven) to be the person whose name is subscribed to

the within instrument, and acknowledged that he/she executed the same for the purposes

therein contained.

WITNESS my hand and official seal this _________ day of ________________ in the year of

20________. My commission expires: ________________________________.

__________________________________

(Notary Printed Name)

__________________________________

(Notary Signature)

Fax to: 877.525.2880 (Attn: IVF\CCC) or

Email to:

(Attn: IVF\CCC) or

Mail to: Piedmont Natural Gas (Attn: IVF\CCC), 2611 Greengate Dr., Greensboro, NC 27406

Identity Verification Form Page 2