Time-of-Day Rate Change Request Form

1. Customer Name on Account: *This question is required.

2. Phone Numbers:

Day *This question is required.

Evening

Cell

3. Mailing Address:

Mailing Address Line 1 *This question is required.

Address Line 2

City *This question is required.

State *This question is required.

Zip Code *This question is required.

4. Service Address:

Service Address Line 1 *This question is required.

Service Address Line 2

City *This question is required.

State *This question is required.

Zip Code *This question is required.

5. Email Address *This question is required. This question requires a valid email address.

6. Account Number (11 digits, found at the top left of your utility bill) *This question is required.

(XXXXXX-XXXXX)

7. Customer Interest in Premise *This question is required.

8. Rate Choice
PLEASE NOTE – the Electric Heat TOD pricing has slightly higher on-peak and off-peak kilowatt-hour (kWh) charges and is exempt from the additional tier component charge, if total consumption exceeds 700 kWh in a month. *This question is required.

By signing below, I understand that I am requesting a rate change for my electric energy. This change will cause my electric energy to be billed at a different cost per kWh. I further acknowledge it is unlawful for any person to provide untrue, deceptive or misleading information or to otherwise misrepresent any aspect of the real property at which utility service are received or requested, as set forth in §26-27 of the Fort Collins Municipal Code. I also understand by requesting this rate change, I am prohibited from requesting another rate change for twelve months. Further requested rate changes in the future could incur a service fee.

9. Signature *This question is required.

Clear

Signature of

10. Date This question requires a valid date format of MM/DD/YYYY.

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