Member Change Request Form

Please feel free to contact us with any questions regarding this information.

Contact Information:
Consumers Energy
2074 242nd Street
Marshalltown, IA 50158
Phone: 641-752-1593 or 800-696-6552
Fax: 641-752-5738

Select One of the Following Options

Check the appropriate area(s) below for the type of change(s) requested to the account(s) referenced.

Member Information

Name(s) on Account *

Account Number(s) *

*New Mailing Address

New Mailing Address

Street Address/PO Box

City/State/Zip

New Joint Member

*Individual to Joint Account

Add a New Joint Member to Individual Account

New Joint Member's Name

Address (if different)

Social Security Number - New Joint Member

Driver's License Number - New Joint Member

Date of Birth - New Joint Member

Phone - New Joint Member

Alternate Phone - New Joint Member

Employer

Email Address - New Joint Member

Signature of New Joint Member

Date Signed by New Joint Member

Member Name Change

*Member Name Change

Name Change of Member (Attach Copy of Marriage Certificate or Divorce Decree)

Marriage Certificate or Divorce Decree

New Name

Driver's License Number - New Name

Date of Birth - New Name

Phone - New Name

Signature using New Name

Date Signed by Member using New Name

Remove Listed Member

*Joint to Individual Account

Remove an Existing Member from an Account

Reason for Change

Death Certificate or Divorce Decree

Name to Remain on Individual Account

Driver's License Number - Individual Account Holder

Phone - Individual Account Holder

Date of Birth - Individual Account Holder

Signature of Individual Account Holder

Date Signed by Individual Account Holder

Add Verified Person to Account

*Authorization to Discuss Account

Authorization to Discuss Account with Someone Other than Member(s)

Name - Other than Member(s)

Driver's License Number - Other than Member(s)

Date of Birth - Other than Member(s)

Phone - Other than Member(s)

Signature of Member

Date Signed by Member

Driver's License Records

Driver's License Number - Existing Account

Privacy & Signature

Privacy Compliance

Member Signature

Date Signed by Member

Joint Member Signature

Date Signed by Joint Member

Signature Disclosure

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Member Change Request Form

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