Identity Verification Form
Upon request by PSNC Energy, this form must be completed to validate an individual’s identity in connection with establishing or maintaining a utility account with PSNC Energy.
Section I
I, _______________________________, the undersigned, do hereby state and declare the following:
PRINTED NAME
This Identity Verification Form concerns utility service at the following service location:
Address: _____________________________________________________________________________
City: ___________________________ State: ____ ZIP: _______ Contact Phone #: _____________
I understand that knowingly making any false or fraudulent statement or representation may constitute a violation of federal, state, or local criminal statutes, and may result in imposition of a fine or imprisonment or both.
Applicant Signature: __________________________________________ Date: __________________
Section II (To be completed by the notary)
State: _________________________________________ County: ________________________________
I do hereby certify that __________________________________ personally appeared before me this
day and is known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he/she executed the same for the purposes therein contained.
WITNESS my hand and official seal this________ day of ______________ in the year 20 _____ .
My commission expires: __________________________
_____________________________________________
(Notary Printed Name)
_____________________________________________
(Notary Signature)
This Identity Verification Form was completed by a notary at the following:
Notary Address: _______________________________________________________________________
City: _________________________________________ State: ___________ Zip: _____________
Identity Verification Form Instructions
Instructions for Applicant:
In order to receive service from PSNC Energy, this Identity Verification Form must be completed. Service will not be provided until the completed form is received by PSNC Energy.
1.Complete all fields in Section I.
2.Present yourself to a licensed notary.
3.Have the licensed notary complete Section II (Request an ink notary stamp so document can be
faxed). The name and address should be the location at which the notary can be contacted (For example‐ XYZ Bank, 123 Main Street, Raleigh, NC 28212 or Notary’s home address).
4.Fax the completed and notarized Identity Verification Form to PSNC Energy at 1‐704‐810‐3122. Once received, PSNC Energy will contact you at the Contact Number provided in Section I on the Identity Verification Form to complete the application process.
Note: The original notarized Identity Verification Form with all fields completed must be received at the address listed below within ten business days or the account is subject to disconnection. We recommend you keep a copy for your records.
5.Mail this completed original form to:
PSNC Energy Receivables Management
PO Box 935
Lowell, NC 28098
6. If you have questions, please contact PSNC Energy at 1‐877‐776‐2427.
