Please feel free to contact us with any questions regarding this information. Contact Information: Consumers Energy 2074 242nd Street Marshalltown, IA 50158 Phone: 641-752-1593 or 800-696-6552 Fax: 641-752-5738 Select One of the Following Options Check the appropriate area(s) below for the type of change(s) requested to the account(s) referenced. Member Information Name(s) on Account Account Number(s) This number will not be longer than 7 digits. New Mailing Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code New Joint Member Add a New Joint Member to Individual Account New Joint Member's Name Address (if different) Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Social Security Number - New Joint Member Driver's License Number - New Joint Member Date of Birth - New Joint Member Phone - New Joint Member Employer Email Address - New Joint Member Signature of New Joint Member Sign above Date Signed by New Joint Member Member Name Change Name Change of Member (Attach Copy of Marriage Certificate or Divorce Decree) Marriage Certificate or Divorce Decree One file only.100 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. New Name Social Security Number - New Name Driver's License Number - New Name Date of Birth - New Name Phone - New Name Signature using New Name Sign above Date Signed by Member using New Name Remove Listed Member Remove an Existing Member from an Account Reason for Change - None -Deceased (provide copy of death certificate)Divorced (provide copy of divorce decree) Death Certificate or Divorce Decree One file only.100 MB limit.Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Name to Remain on Individual Account Social Security Number - Individual Account Holder Driver's License Number - Individual Account Holder Phone - Individual Account Holder Date of Birth - Individual Account Holder Signature of Individual Account Holder Sign above Date Signed by Individual Account Holder Add Verified Person to Account Authorization to Discuss Account with Someone Other than Member(s) Name - Other than Member(s) Social Security Number - Other than Member(s) Driver's License Number - Other than Member(s) Driver's License Number - Other than Member(s) Date of Birth - Other than Member(s) Phone - Other than Member(s) Signature of Member Sign above Date Signed by Member Driver's License Records Add SS# and Driver's License Number to Existing Account Social Security Number - Existing Account Driver's License Number - Existing Account Privacy & Signature Privacy Compliance - FOR PRIVACY COMPLIANCE, I (WE) AUTHORIZE CONSUMERS ENERGY TO CHANGE THE ELECTRIC ACCOUNT(S) NOTED ABOVE TO REFLECT THE CHANGES MARKED ABOVE. CHANGE REQUESTS BECOME EFFECTIVE WHEN THIS FORM IS SUBMITTED TO CONSUMERS ENERGY. Member Signature Sign above Date Signed by Member Joint Member Signature Sign above Date Signed by Joint Member Signature Disclosure - For the purpose of Consumers Energy online forms, when the word(s) "signature" "member signature" "joint member signature" or "signature of responsible party" appears, a typed, legal name is an acceptable substitute. As long as the complete, legal name appears in each blank for which a signature was requested, the form is accurate and binding (pending accurate completion of all other form sections). It is not necessary to print and sign the form if users plan on submitting the form electronically. I agree that my electronic signature on this agreement/document has the same effect as a signature signed in ink. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
