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Release of Utility Historical Information

This release authorizes Ameren Illinois to provide the historical data with regard to units of gas and/or electric services for the following customer.

Customer Information

* required information

Service Address

* required information

Second Account Information

Third Party

A Third Party is a person or company that the customer has formally authorized to receive their historical data.

* required 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.

Any person who submits false or inaccurate information as part of this form may be subject to fines and/or punishment pursuant to applicable federal and/or state laws and regulations.

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