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Letter of Credit Request

AZ_Community_RES_Letter_Of_Credit

Date*

1. First Name*

Last Name*

2. Account Number

3. Service Address*

City*

State*

Zip Code*

4. Telephone*

5. E-mail*

6. Fax

7. Mailing Address

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8. Check one:*

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9. I hereby authorize Liberty Utilities to release the credit history for the above account to the following third party:*

10. Please type your name as you signature.*

Under penalties of perjury I declare that to the best of my knowledge and belief the above information is true correct and complete.

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