Transfer Utility Service Use this form to request a service transfer to a location within the KUA territory. Account Holder Information KUA Account Number * (Located on your KUA bill) First Name * Middle Name Last Name * Social Security / Passport Number * The above number is my: * Social Security NumberPassport Number Date of Birth * Birth MonthJanFebMarAprMayJunJulAugSepOctNovDec Birth Day12345678910111213141516171819202122232425262728293031 Birth Year20152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 Driver's License Number Driver's License State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvania Rhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPR- Puerto RicoOther Country Upload Image / PDF of Driver's License Your Message Email Address (required for confirmation) * Employers Name Employment Information (If retired or unemployed, enter your last employers name.) Employers Phone Number Length of Employment Employment Years Employment Years Spouse or Roommate Information If you are not providing spouse or roommates information please choose none and skip to the next section. Please Choose One None - Skip this section if you do not have a Roommate / SpouseI am providing my Spouse's informationI am providing my Roommate's information Spouse or Roommate's Information First Name Middle Name Last Name Social Security/Passport Number The above number is my: Social Security NumberPassport Number Date of Birth Birth MonthJanFebMarAprMayJunJulAugSepOctNovDec Birth Day12345678910111213141516171819202122232425262728293031 Birth Year20152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 Spouse or Roommate's Employer Name Employer's Phone Number Old Service Location Information Address of the location terminating service. Street Address of the Old Service Location * Apartment / Unit Number City * Zip Code * If renting please enter the Complex/Landlord information. Complex / Landlord Name Complex / Landlord Phone Number Upload Image / PDF of Lease Is this property going to be used as a short term rental? NoYes New Service Location Information Address of the location needing service. Street Address of the New Service Location* Apartment / Unit Number City * Zip Code * Home / Location Phone Number (Having the correct phone number in our system will help automate your phone requests.) Cell / Other Phone Number Alternate Billing Address (Optional) If you would like to have your bill sent to an alternate address please complete this section. Name Street Address Additional Street Address Apartment / Unit Number City State / Province AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinois IndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontana NebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvania Rhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPR- Puerto RicoOther Country Country Zip Code Service Activation Date/Disconnect Dates Select the date you would like the new service started and the old service terminated. Date must be at least 3 days from the current date. Dates cannot be requested on a holiday or weekend. Enter the New Service Location Activation Date Service Activation MonthJanFebMarAprMayJunJulAugSepOctNovDec Service Activation Day12345678910111213141516171819202122232425262728293031 Service Activation Year201520162017201820192020 Enter the Old Service Location Disconnect Date Service stoppage MonthJanFebMarAprMayJunJulAugSepOctNovDec Service stoppage Day12345678910111213141516171819202122232425262728293031 Service stoppage Year201520162017201820192020 Additional Comments Round Up my electric bill to the nearest dollar: * YesNo Small change can add up and help transform lives! Through this voluntary program, all money donated/received will go towards providing financial assistance through the Good Neighbor Utility Assistance Fund. If you choose to participate, your electric bill will be rounded up to the next whole dollar amount. For example, a customer’s bill of $110.73 would be automatically rounded up to $111.00, with the additional 27 cents going to the utility’s Good Neighbor Utility Assistance Fund. The donations are then matched dollar-for-dollar by the utility. The Good Neighbor Utility Assistance Fund provides emergency utility bill payment assistance to individuals and families in Kissimmee facing a temporary financial crisis. Important Note Terms and Agreement: By selecting the agree button, the account holder is authorizing KUA to activate service and to utilize the information obtained through this application, including the account holder's social security number, to review the customer's credit history. The account holder understands that a copy of the lease or purchase agreement must be received by KUA to complete the service activation process. The account holder also agrees that all information faxed to KUA is at the account holders own risk and agrees to hold KUA harmless for any liability suffered by the account holder or anyone else due to the facsimile transmission of this information. By submitting this application I understand that I am on notice from KUA that my services may be initiated immediately without further notice. I also understand and agree that it is the account-holder or account-holder representative’s sole responsibility to notify KUA if such immediate restoration or initiation is not desired. I agree * You must agree for the form to process. *Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public-records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing. **Please note: If you don’t receive an immediate confirmation email in your inbox it is possible KUA did not get the information you submitted. If this occurs, please resubmit your information or call customer service at 407-933-9800. Thank you. The Customer Service Center is available Monday-Friday from 7:00 AM till 6:00 PM excluding holidays to respond to online requests. If you need immediate attention please call 407-933-7777 24-hours a day.