Customer Information
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1UTILITY PARTNERS OF AMERICA
Complete this form and return with your utility bill payment or TO ENROLL BY
PHONE, CALL 1-864-269-2755
_____ Yes, I would like to enroll in the UPA plan. I authorize my Utility Company to
charge my account:
___________ $3.00/mo
Standard Electric Water Heater
___________ $3.50/mo
Gas Water Heater
___________ $3.50/mo
Water Lines
___________ $1.50/mo
Repair Only Water Lines
___________ $6.00/mo
Electric Heater & Water Lines
___________ $6.50/mo
Gas Heater & Water Lines
Utility Company
Blue
Rural Water Company, Inc.
Ridge
State ___________ Account No. ___________________
City ____________________
# of Units: ___ 30-Gallon ___
40-Gallon ____ 50-Gallon _____ Gas ___ Electric ____
Location of Water Heater: __ Attic ____ Garage ____ Crawl Space ____ Other (specify)
Does your line run below any structure, driveway or other obstruction? ________________
Specify obstructions: ______
CUSTOMER INFORMATION
Name on Account ____________________________________________________________
Address ____________________________________________________________________
City ______________________________ State _____________ Zip ___________________
Home Phone _________________________ Work Phone ____________________________
Signature _______________________________________ Date ______________________
UPA reserves the right to inspect any or all water heaters and any or all water lines prior tc
accepting them on the program.
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