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Account Agent Designation Statement

This statement will confirm that the Customer has entered into an agreement with a designated Agent effective as of the date specified below. The Agent will serve as his/her/its Agent for the purpose of arranging and making all decisions regarding service on his/her/its behalf for the Ameren Illinois Account Number(s) listed below. Ameren Illinois will assume this Customer-Agent relationship will remain in force until a Termination of Account Agent Designation Statement is received revoking the designation of this Agent to act on the Customer’s behalf.

The Agent is authorized to make decisions regarding the account(s) noted below. Ameren Illinois may rely on any representation made by Agent regarding this account(s) and need not question the authority of the Agent to act on the Customer’s behalf. Ameren Illinois shall not be liable for any action taken in response to a representation made by Agent. Customer shall be solely liable for any action taken by his/her/its Agent on the Customer’s behalf, including any action taken by the Company at the Agent’s request.

Customer Information

Agent Information

I affirm that I am the person who prepared this form, or that I have prepared and submitted this form as the duly authorized executor, guardian, authorized officer, or agent of such named person, and that I acknowledge that I have read and understood all of the questions in this application and that all of the information submitted in this application is true and correct to the best of my knowledge, and that all responses to the questions are full and complete, omitting no material information.

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