I, ___________________________________________ (printed name), owner of the property located at
____________________________________________________ (Residential Address, City, State, Zip Code)
Hereby appoint [INSERT YOUR COMPANY NAME HERE] to represent and act on my behalf when
establishing and disconnecting utility services. [INSERT YOUR COMPANY NAME HERE]’s powers
include but are limited to:
1. Authorize to put all Utilities in Owners name and conditioned to automatically transfer responsibility when
Premises is vacant.
2. Obtaining information or documents from any governmental or privately owned utility agency necessary
for the establishment of the utility service.
3. Preparing applications, providing information, and performing any other act reasonably requested by the
governmental or privately owned utility agency in order to establish or disconnect utility service.
A. This shall be construed only to establish and disconnect utility services on my behalf.
B. [INSERT YOUR COMPANY NAME HERE] shall not be liable for any loss that results from a
judgment error that was made in good faith.
C. Owner agrees to immediately provide funds to [INSERT YOUR COMPANY NAME HERE], if
necessary to pay any and all deposits or establishment fees to connect utilities.
D. [INSERT YOUR COMPANY NAME HERE] shall provide an accounting for all funds handled and
all acts performed as my representative, if I so request or if such a request is made by any authorized
personal representative or fiduciary acting on my behalf.
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