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SSA Name

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Lead Token

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Affordable Housing Organization

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Assistance Program

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Advantage Services Coordinator

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Sales Agent Email

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Customer Name on Utility Account

First Last

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Zip Code*

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Utility*

Phone*

Email*

Utility Account Number*

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Percentage Allocation

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Annual kWh Usage*

If you have not lived at your current address for 12 months, please calculate 12 full months of usage using your existing information.

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SSA Version

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CSG

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Waitlist CSG

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Anticipated COD

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