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Name Change Due to Divorce Form

"*" indicates required fields

This document is to certify that I,

Name*

First Last

,am a member of Coast Electric (Print Name) Power Association, Member #:

Member #*

and I have recently (Member Number) divorced. I request Coast Electric to change the name of my electric account from:

From Name*

First Last

to:

To Name*

First Last

Divorce Decree*

Max. file size: 50 MB.

Please upload a copy of the Divorce Decree.

Date*

Signature*

Please complete information below:

Member Home Phone*

Member Cell Phone*

Member Email*

This institution is an equal opportunity provider and employer.

This field is for validation purposes and should be left unchanged.