Name Change Form

Blountville Utility District

P.O. Box 469 | Blountville, TN 37617 | 423-323-2189

Name Change Form

Current Customer Name

Acknowledgement

I submit this name change and acknowledge all information to be true and correct.

Current Customer Name (Signature)

New Customer Name

Acknowledgement

I submit this name change and acknowledge all information to be true and correct.

New Customer Name (Signature)

Account Number

Phone Number

Physical Address

City

State

Zip Code

Mailing Address

City

State

Zip Code

Effective Date

Please provide a marriage license, new photo ID, or death certificate:

Location