Term Account Agent Designation

Click here to view the 'Focused Energy. For Life' page

Termination of Account Agent Designation Statement

Questions?

This statement will confirm that, as of the effective date specified below, the named customer revokes the designation of the specified agent for the listed account numbers.

Effective Termination Date: *

Customer Information

* required information

Company Name: *

Contact First Name: *

Contact Last Name: *

E-mail Address: *

name@domain.com

Confirm E-mail Address: *

Phone Number: *

555.123.4567

Account Number: *	Where is this?
Add Another Account Number

Account Number
Your ten-digit account number located on your Ameren bill.

Agent Information

* required information

Company Name:

Contact First Name: *

Contact Last Name: *

Address: *

Address:

City: *

State: *

ZIP Code: *

E-mail Address: *

name@domain.com

Confirm E-mail Address: *

Phone Number: *

555.123.4567

After Termination Date Send Bills To:*

Customer
Other

City: *

State: *

ZIP Code: *

I revoke the designation of agent for the account numbers specified above. I affirm that I am the person who prepared this form, or that I have prepared and submitted this form as the duly authorized executor, guardian, authorized officer, or agent of such named person, and that I acknowledge that I have read and understood all of the questions in this application and that all of the information submitted in this application is true and correct to the best of my knowledge, and that all responses to the questions are full and complete, omitting no material information.

Account Number

Your ten-digit account number located on your Ameren bill. Agents, suppliers and consultants can enter zeros.

Any person who submits false or inaccurate information as part of this form may be subject to fines and/or punishment pursuant to applicable federal and/or state laws and regulations.