Consent To Disclose Utility Customer Information printable pdf download

[Insert Utility Contact Information Here]

CONSENT TO DISCLOSE UTILITY CUSTOMER INFORMATION

This form was prepared by the Public Service Commission of Wisconsin as required by Wis. Stat. § 196.137(4).

Requesting Entity Name (if applicable) ___________________________________________________

Contact Person_________________________________________________________________

Mailing Address________________________________________________________________

Phone_(_____)____________ Fax_(_____)____________ Email_________________________

INFORMATION REQUESTED

The person or entity identified above requests customer information, including billing and usage data

related to: □ electric; □ gas; □ water; or □ all services provided by the u lity. Such informa on

includes your account balance, payment history and total use per billing period. The information

provided by the utility may include any other information regarding your account contained in utility

records.

CUSTOMER’S CONSENT

Your information is treated as private by the utility and can only be disclosed as permitted by Wis.

Stat. § 196.137. You are not required to authorize the disclosure of your customer information, and

your decision not to authorize the disclosure will not affect your utility service.

By signing this form you acknowledge and agree that you are the customer(s) of record for this

account and that you authorize the utility to disclose your customer information to the requesting

entity listed on this form. This consent is valid until you terminate your service, or withdraw consent

by sending a written request with your name and service address to the utility at the address

specified at the top of this form. You may terminate this consent at any time.

Please complete this form and return it to the utility either by:

 Email:________________________________________________________________________

 Fax:_(_____)__________________________________________________________________

 Mail:________________________________________________________________________

CUSTOMER ACCOUNT NUMBER________________________________________________________

SERVICE ADDRESS____________________________________________________________________

PRINTED CUSTOMER(S) NAME_________________________________________________________

SIGNATURE OF CUSTOMER(S) __________________________________________________________

DATE SIGNED____________________ CUSTOMER PHONE NUMBER_(_____)___________________

Please complete separate consent forms for each utility account.

Consent To Disclose Utility Customer Information