Landlord contract cancellation

Dear Customer:
Please be advised that in the event, for any reason, the premises are vacated or service is disconnected, Black Hills Energy will not be responsible for any damages to the premises as a result of the premises not receiving utility service. Cancellation will not be effective until this form is verified by Black Hills Energy.

Name

ID type

Social Security

Federal ID

Mailing Address

Email Address

Phone

If service to Property Address(es) listed below is currently active in above name, should the service be turned off?

Yes

Date power should be turned off

Property address(es)

Enter the property address(es) that will fall under this contract. Separate multiple addresses by pressing the enter key and beginning the next address on a new line. Or you can attach a list of your properties below. Format: Street Address, Apt #, City, State, Zip, Account Number

Select a file

One file only.
48 MB limit.
Allowed types: gif, jpg, png, pdf.

I AUTHORIZE THE PROCESSING OF THE INFORMATION CONTAINED IN THIS ELECTRONIC FORM

Person Submitting Form