Customer Account Name Change Form

Customer Account Name Change Form

Hernando County Utilities Department
Account Number*
Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Change

Marriage/Divorce

Required: updated Driver's License and/or Marriage Certificate and/or divorce decree.

Please note: If your name is not currently on the account, you are required to open a new account and complete service applications with current deposit and service charge requirements in effect.

Addition of Name

The person being added to the account is equally responsible for payment of all fees or charges due on the account. Any deposits or credits on the account will be refunded payable to both account holders.

Correction of Name

Required: updated Driver's License and/or supporting documentation. For business name change, a valid FEI/EIN number is required.

Death of Account Holder

Required from surviving spouse: death certificate and marriage certificate, if applicable. Required from Representatives: court orders and/or Power of Attorney. Please note: heirs are required to open new accounts and complete service applications with current deposit.
Reason for Name Change (**Please see below for requirements**)*
Present Customer Information
Account Holder Name*

First NameLast Name
Photo ID Number*
Social Security Number (**Last four digits ONLY**)*
Secondary Account Holder Name

First NameLast Name
Photo ID Number
Social Security Number (**Last four digits ONLY**)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
New Customer Information
Attach Photo ID(s)*

Upload up to 4 images for each account holder as applicable.
Cancelof
Attach Supporting Documentation (Marriage Certificate, Death Certificate, Court Orders/ and or Power of Attorney, etc.)

Upload up to 4 files
Cancelof
New Name*

First NameLast Name
Photo ID Number*
Social Security Number (**Last four digits ONLY**)*
New Name (Secondary Account Holder)

First NameLast Name
Photo ID Number
Social Security Number (**Last four digits ONLY**)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
IMPORTANT INFORMATION:

AUTHORIZATION FOR CUSTOMER ACCOUNT INFORMATION CHANGE: I certify that I am the present account holder and as such am authorized to initiate the requested change. I acknowledge that this authorization is an amendment to the original service contract on file with Hernando County Utilities. I understand that any credit balance will be transferred to the new named account holder, and I forfeit rights to these funds.

CONTRACTUAL OBLIGATIONS OF NAMED ACCOUNT HOLDERS: I agree to assume responsibility for the payment of all water and/or sewer fees and charges at the above service address. I further agree to conform to the rates, rules and regulations of the Hernando County Water and Sewer District for water and/or sewer service which are now or hereafter in force. I agree to accept all responsibilities entailed with this account.
Customer Signature*

Clear
Date*

MonthDayYear
Date
Customer Signature (Secondary Account Holder)

Clear
Date

MonthDayYear
Date
New Customer Signature*

Clear
Date*

MonthDayYear
Date
New Customer Signature (Secondary Account Holder)

Clear
Date

MonthDayYear
Date
Should be Empty:

Customer Account Name Change Form

Present Customer Information

New Customer Information