Account Authorization Form

Sewer Account Number:

Account Name:

Service Address: *

Service Address City, State, Zip:

Mailing Address Street:

Mailing Address City:

Mailing Address State:

Mailing Address Zip:

Phone Number: *

Email:

Effective Date of this Request: *

Authorized Person 1: *

For Account Verification: Authorized Person 1 (Last 4 of SSN) or (Date of Birth) *

Authorized Person 2:

For Account Verification: Authorized Person 2 (Last 4 of SSN) or (Date of Birth)

Authorized Person 3:

For Account Verification: Authorized Person 3 (Last 4 of SSN) or (Date of Birth)

By electronically signing this form, I hereby authorize Superstition Mountains Community Facilities District No. 1 (the "District) to release account information upon request to the person(s) named. I understand that disclosure may be in the form of, but not limited to copies of monthly statements, copies of delinquent or disconnection notices, customer correspondence and/or verbal communication. I acknowledge that the authorized person(s) is not recognized as my legal representative and does not have legal power of authority to make changes to the account. I have been advised that the District will not provide any notification to me when information is released. I assume responsibility for notifying the District if, and when, it should become necessary to revoke this authorization.

I agree to the terms and conditions stated above and I understand by checking this box and typing my full name below, this constitutes a legal signature as the owner of the above mentioned property. *

Signature: (Please type your full name.) *

Enter the text you see in the security image: