Identity Verification Form

T o Be Co m p let ed b y Ap p lican t Please be sure that the information is printed clearly.

( Para ser co m p let ad o p o r el so licit an t e) ( Por favor asegúrese de escribir la informacion claramente)

Last Name (Apellido) (1) Cañizalesz First Name(No mbre) Gregori

(2) MI (3) J
Date of birth (Fecha de nacimien to ) (4) 10/25/1986
Phone Number (5)(812) 9232907 Alternate Phone Number (6)(812) 4163148 (Telefono)
(Telefono alternativo )

Address where service is requested 625 DARTMOUNTH DRIVE APARTMENT 25 CLARKSVILLE Apt. # (8)
(7)
29
25
(Direccion donde se solicita servicio) (dpto#)
City (Ciudad) CLARKSVILLE State (Estado)
(9) (10) IN Zip Code (Codigo postal) (11) 47129

Address on Govern men t issued photo ID (12) 625 DARTMOUNTH DRIVE APARTMENT 25 CLARKSVILLE
(Direccion que aparece en su identificacion con foto emitida por el gobierno )
City (Ciudad) (13) Clarksville State (Estado ) (14) IN Zip Code (Codigo postal) (15) 47129

Type of Government issued photo ID (16) PASSPORT ID #(17) 163759205

(Tipo de indentificacio n con foto emitida por el gobierno) (Numero de identificacion )
Example: drivers license, passport, etc. (Ejemplo: licencia de conducir, pasaporte, matricula consular)

Signature of Applicant (18) GREGORI CAÑIZALE Z Date (19) 10/18/2023

(Firma del Aplicante) (Fecha)
**The signature date must match the date listed below by the notary
(**La fecha de su firma debe coincidir con la fecha de la firma del notario)
T o Be Co m p let ed b y No t ary Please be sure that the information is printed clearly.
(Para ser completado por Notario Publico) ( Por favor asegúrese de escribir la informacion claramente)
I certify that (20) personally appeared bef ore me this day,
(21) / / , and is the person whose name is subscribed to the within instrumen t, and
acknowle dg ed that he/she executed the same f o r the purpose therein contained.

(22) _ (23)

Notary Signature Notary Name typed, printed or stamped

(24) _ (25)

Notary Title or Rank My Commission Expires

(26)

Notary Public Seal

Ret u rn co m p let ed f orm t o CenterPoint

Cu st o mer Service at : ( En víe est e f o rmu lario co m pleto a: )

Fax to: (812) 491-4053 Mail to: CenterPoint Energy

(Por fax) (Por correo) Attention: Customer Service
Email to: IDVerif ication@centerpointenergy .com P.O. Box 209
(Por correo electrónico) Evansville, IN 47702-0209