REQUEST FOR THIRD-PARTY NOTIFICATION

BENCO Electric Cooperative offers a Third-Party notification system to all members. This program gives members the opportunity to request that a person or organization of their choice be notified should electric service become subject to disconnection. A third-party can be a friend, relative, church or organization and can be helpful to those who live alone, are elderly, disabled, ill or a landlord and/or renter.

The member, as well as the designated third-party, would be notified of electric service subject to disconnection. The third-party could contact BENCO and confirm the member’s inability to pay and set up a payment arrangement if desired. This helps avoid the hardship that would result from disconnecting service. Please note the third-party would not be responsible for payment of the member’s bill.

If you would like to name a third-party to a BENCO account, please complete the form below:

Date:

MM

DD

YYYY

Account Holder Name:

First Name

Last Name

Account Holder Service Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Account Holder Phone:

(###)

###

####

BENCO Account #:

Third-Party Name:

First Name

Last Name

Third-Party Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Third-Party Phone:

(###)

###

####

Third-Party Email:

Acknowledgement Agreement

By checking this box I acknowledge that BENCO Electric Cooperative has my permission to provide information to and accept information from the third-party listed above.

Yes

BENCO will make every effort to send a copy of the disconnection notice to the designated third-party. BENCO does not assume liability for failure of a third-party to receive or act upon the notice.