Third Party Notification Form
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12211 Elk River Road
YAMPA VALLEY ELECTRIC ASSOCIATION, INC.
3715 E. US Hwy 40
Steamboat Spgs, CO 80487
ELECTRIC SERVICE REQUEST
C
raig, CO 81626
FAX 970-871-2271
FAX 970-824-7134
PLEASE PRINT
PHONE 970-879-1160
PHONE 970-824-6593
THIRD PARTY NOTIFICATION
This form gives YVEA customers the opportunity to designate a third-party to whom notices of
discontinuance of service for non-payment will be delivered. The third-party designee will not
receive copies of monthly bills or notices for normal requested disconnection of service.
Notification of a third-party does not circumvent the customer’s responsibility for payment of
their electric account. The third-party shall not be responsible for the bill.
CUSTOMER’S NAME: _____________________________________________________________________________________
MAILING ADDRESS: ______________________________________________________________________________________
PHYSICAL ADDRESS: _____________________________________________________________________________________
CITY: ________________________________________________ STATE: ______________ ZIP: ________________________
DAYTIME TELEPHONE NUMBER: __________________________________________________________________________
YVEA ACCOUNT NUMBER: _______________________________ SERVICE MAP LOCATION: _______________________
The third-party to be notified in the event of possible discontinuance of service for non-payment:
THIRD-PARTY NAME: ___________________________________________________________________________________
MAILING ADDRESS:
___________________________________________________________________________________
CITY: ________________________________________________ STATE: ______________ ZIP: ________________________
DAYTIME TELEPHONE NUMBER: __________________________________________________________________________
_____________________________________________________
________________________________________________
Customer Signature
Third-Party Signature
_________________________________
___________________________
Date
Date
INPUT INTO THE YVEA BILLING SYSTEM BY ____________________ ON _________________________________.
This agreement is not valid until signed by customer & third-party person and initialed and dated by a YVEA employee. A copy of
this form will be mailed to the third-party once it is initialed and dated by a YVEA employee.
REFERENCES: Operating Procedure 213
R&R Sheet 41, #13
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