Authorization To Receive Customer Information Or Act On A Customer'S Behalf
Download a blank fillable Authorization To Receive Customer Information Or Act On A Customer'S Behalf in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Authorization To Receive Customer Information Or Act On A Customer'S Behalf with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2AUTHORIZATION TO: RECEIVE CUSTOMER
INFORMATION OR ACT ON A CUSTOMER’S BEHALF
THIS IS A LEGALLY BINDING CONTRACT – READ IT CAREFULLY
I,
NAME
TITLE (IF APPLICABLE)
of
(Customer) have the following mailing address
NAME OF CUSTOMER RECORD
, and do hereby appoint
MAILING ADDRESS
CITY
STATE
ZIP
of
NAME OF THIRD PARTY
MAILING ADDRESS
CITY
STATE
ZIP
to act as my agent and consultant (Agent) for the listed account(s) and in the categories indicated below:
ACCOUNTS INCLUDED IN THIS AUTHORIZATION
30_______________
1.
SERVICE ADDRESS
SERVICE ACCOUNT NUMBER
30_______________
2.
SERVICE ADDRESS
SERVICE ACCOUNT NUMBER
30_______________
3.
SERVICE ADDRESS
SERVICE ACCOUNT NUMBER
(For more than three accounts, please list additional accounts on a separate sheet and attach it to this form)
INFORMATION, ACTS AND FUNCTIONS AUTHORIZED – This authorization provides authority to the Agent.
The Agent must thereafter provide specific written instructions/requests (e-mail is acceptable) about the
particular account(s) before any information is released or action is taken.
In certain instances, the
requested act or function may result in cost to you, the customer. Requests for information may be limited to
the most recent 12 month period.
I
authorize my Agent to act on my behalf to perform the following specific acts and functions
(Customer)
(initial all applicable boxes):
1.
Request and receive billing records, billing history and all meter usage data used for bill calculation for all of my
1
account(s), as specified herein, regarding utility services furnished by the Utility.
2.
EPA Benchmarking
3.
Request and receive copies of correspondence in connection with my account(s) concerning (initial all that apply):
a.
Verification of rate, date of rate change, and related information;
b.
Contracts and Service Agreements;
c.
Previous or proposed issuance of adjustments/credits; or
d.
Other previously issued or unresolved/disputed billing adjustments.
4.
Request investigation of my utility bill(s)
5.
Request special metering, and the right to access interval usage and other metering data on my account(s).
6.
Request rate analysis.
7.
Request rate changes.
8.
Request and receive verification of balances on my account(s) and discontinuance notices.
1
The Utility will provide standard customer information without charge up to two times in a 12 month period per service account. After
two requests in a year, I understand I may be responsible for charges that may be incurred to process this request.
Form 14-796
Page 1 of 2
4/2011
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application Form - Person Freed For Adoption But Not Subsequently Adopted Or Person Acting On Adopted Person's Behalf - Vs210c
Legal
Authorization To Receive Confidential Tax Information For Nyc-3a Tax Filers Form - New York Finance
Financial
Related Categories
Parent category: Business