Capital Credits Form

I am contacting you with regard to my account

Name

First Middle Last

List spouse or roommate names

Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Current Phone

Email*

List all known former addresses and the reason you're contacting Dakota Electric:

I am contacting you on behalf of another member

Is the member deceased?

Yes
No

If yes to above, please list surviving spouse or Legal Representative's name and current addresses:

Has the member's name changed? If so please list the previous name:

List the member's current name:

Your Name:

Your address (in case we need to contact you):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Current Phone:

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