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(616) 772-6212
Regular Hours
M-F: 8am-4pm
Office Hours
(616) 772-2001
After Hours Emergency
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Customer Information Survey Form

The Zeeland Board of Pubic Works wants customers to know the ZBPW will do everything it can to prevent shut-offs during the winter heating season, including working with customers to develop a payment schedule. Moreover in assigning priorities for electric service restoration, the ZBPW needs to know where customers with medical equipment dependent upon electric supply are located. To assist us in this effort, attached please find a Residential Electric Customer Survey.

Residential Customer Information Survey Form

If you have already provided this information and have no changes, it is not necessary to resubmit.

Account Information

Head of Household(Required)
Service Address(Required)
Billing Address(Required)
Additional Contact Name
Please Indicate
Landlord
Address

MM slash DD slash YYYY

Low Income

Household income must be less than 150% poverty level per USDHHS. See chart for guidelines. If qualified, please provide copy of recent W2.

If you answer yes to any of the following, we will reach out to receive verification.

Food stamps
Medicaid
State Emergency Relief

Medical Emergency/Critical Care

We will reach out to get documentation from Doctor/Public health official starting type of equipment and that interruption of service would be immediately life threatening.
Name of patient
MM slash DD slash YYYY
MM slash DD slash YYYY

Military

We will reach out to receive verification if needed.
Do you have active duty status?
Is household income reduced due to active status:
Do you require shut-off protection:

Residential Customer Information Survey Form

Download PDF

In order to keep the associated customer information current, annually the ZBPW will distribute this survey. We request customer’s submit an update whenever their status changes.

Low-income Customers

Low-income Customers, or those who fall behind on their bills during the winter months, should contact our Customer Service Department at (616) 772-6212. Our representatives will be happy to work with you on a payment plan.

Military Families

Families with active members of the U.S. Military are also protected from shut-offs. Please contact our Customer Service Department at (616) 772-6212.

Medical Alert Families

Completion of this form verifies that a medical emergency does exist in your home, that there is medical equipment dependant on electric, and continuation of your electric service is vital to the health and well-being of the patient listed.

Senior Enrollment

If you are a customer 65 or older, please let us know. Call (616) 772-6212.