UniSource Safety Net Enrollment Form

Safety Net Enrollment Form
Customer Information

Fields marked with an asterisk are required. Please enter your information below.
Customer Name*

First NameLast Name
Do you know your Account Number?*

YesNo
Enter your Account Number*
10-digit number, please include any leading zeroes
Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Safety Net Party Information

Enter the information below for the party that you wish to receive your overdue monthly bill if you fall behind. Information must be different from the customer's. Fields marked with an asterisk are required.
Safety Net Party's Name (Must be different)*

First NameLast Name
Community Agency
If applicable
Safety Net Party's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Safety Net Party's Email*
example@example.com
Safety Net Party's Phone Number
Please enter a valid phone number.
I acknowledge and agree that I have obtained consent to provide the above information to UniSource Energy Services on behalf of the third party listed above and that such third party has also agreed to receive a copy of your overdue bill. I confirm I am the account holder on record submitting the information. UniSource Energy Services will only use this information for the purpose of the Safety Net Program.

You may voluntarily provide the personal information required to complete this form. UniSource Energy Services uses this information to fulfill the purpose for which it was obtained. To find out more about the categories of personal information UniSource collects and the purposes for which such information will be used, please refer to our Privacy Policy.
I agree to the terms and conditions*

Acknowledgement Agreement
Please verify that you are human*
Should be Empty:

Safety Net Enrollment Form

Customer Information

Safety Net Party Information