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Request to Authorize User on Account

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Current Power Outage

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February 11, 2020

We are aware of a power outage first reported at 8:03 a.m. today in the Monticello, Cuchillo and Winston areas affecting a small amount of customers. It was restored at to all customers by 10:26 a.m.

A winter storm has since arrived in our service territory. If you experience an outage, please contact us with your location.

If you have medical emergency, call 9-1-1. If you are at risk due to cold weather, please contact emergency services for your service area to inquire on how to get to a warming station.

You may call us at 575-744-5231 or our dispatch center at 1-888-336-3380.

Date

Member's Name

Last 4 of SSN

Authorized User(s):

Name

Phone Number

Mailing Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Name

Phone Number

Mailing Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Additional Names

Accounts Included in this Authorization

All Current Accounts (list below)

All Current and Future Accounts (list below)

Specific Account Numbers (list below)

Account Numbers

Type of Authorization/Access

Balance Inquires & Payments

Change or Adjust Budget Payment Plan

Letter of Credit

Sign for Payment Arrangements

Copy of Bill & Delinquent Notice

Payment History

Capital Credit Inquires

Consumption History

Add Name to Bill (Account Level)

Member Signature

Sign above

I am acting on behalf of the member as Power of Attorney

Last Name

First Name

Please provide Power of Attorney Documentation

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Power of Attorney Signature

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Statement of Non-Discrimination

In accordance with Federal civil rights laws and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

1. Mail: US Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410

2. Fax: (202) 690-7442; or

3. Email: program.intake@usda.gov

Sierra Electric Cooperative, Inc. is an Equal Opportunity Provider and Employer