Additional Account Contact and Agreement of Financial Responsibility for Account

(Part 1 and Part 2 must both be completed to allow additional person to be added as account contact)

PART 1:

I, ______, authorize Holmes-Wayne Electric Cooperative, (printed name of account owner) Inc. to add ______as additional contact for (printed name of additional contact) Account Number ______, effective ______. (HWEC Account #) (date)

X______Signature (Account Owner) Date

PART 2:

I, ______, authorize the above account owner and Holmes- (printed name of additional contact) Wayne Electric Cooperative, Inc. to add my name to the above mentioned account as an additional contact, and in doing so, agree to be financially responsible for any unpaid balance on this account.

I further understand that, as specified in the Holmes-Wayne Electric Cooperative, Inc. Code of Regulations, Article I, Section 5, which states that “Applications for joint membership shall not be accepted”, I will not be considered an owner of this account and will not be entitled to any of the rights of membership including capital credit allocations or retirements.

X______-____-______Signature (Additional Contact) Social Security # Date