Csd Form 081 - Client/customer Consent Form And Authorization - California Department Of Community Services And Development
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2CLIENT/CUSTOMER CONSENT FORM AND AUTHORIZATION
The California Department of Community Services and Development (CSD) is a state
agency that oversees energy assistance programs for low-income families. Some of
these services include helping families pay their utility bills or installing energy-efficient
appliances and systems to reduce energy use and expenses. CSD also works with other
organizations and programs that provide related services.
CONSENT (What you are agreeing to when you sign this form)
By signing this form, you give your consent (permission) to CSD, its contractors, consultants, other federal or state agencies
(CSD Partners) and to your utility company and its contractors, to share information about your household’s utility account,
energy usage and/or other information needed to provide the services and benefits to you described on the back of this form.
1. NAME(S) AND MAILING ADDRESS
Your Name
(Applicant)
If your utility bill is in someone else’s name, enter that name here
and initial for authorization (A,B,C)
Your mailing address (Street)
Unit Number (if any)
Your mailing address (City)
State
Zip Code
2. UTILITY SERVICE ADDRESS
Check here if your utility service address is different from your mailing address.
If you checked the box, please provide your utility service address information below:
Your Utility Service Address (Street)
Unit Number (if any)
Your Utility Service Address (City)
State
Zip Code
CA
3. UTILITY INFORMATION
Please enter your utility company name and service account number below (you can find the account number on your bill). If
different companies provide your electricity and gas services, please enter the name and account number for both utilities.
Name of Utility Company
Service Account Number
Name of Utility Company (if you have a second Utility Company)
Service Account Number
AUTHORIZATION
Applicant and Utility Bill customer must sign and initial below
(If client applying for services is not the person whose name is on the account (i.e., the utility customer of record),
both persons must initial and sign this form)
By initialing and signing below, I acknowledge and authorize my utility company, CSD, and CSD Partners to release upon
request and/or to receive my information as described, exclusively for the purposes stated in this Authorization for up to 36
months unless revoked as explained on the back of this form:
Client/Customer Initials
Utility company billing records: account name, service address, billing history and account
/
A
balances, as needed for processing utility bill assistance and emergency payments.
Client/Customer Initials
1) Meter usage and energy consumption data, including up to 12 months of historical data prior to
the date of my signature below; and 2) any information concerning prior weatherization of dwelling
/
B
(if weatherized, date and measures installed).
Client/Customer Initials
Household income, composition and other information needed to determine my eligibility for
energy assistance programs administered by CSD and/or CSD Partners.
/
C
Signature of Client/Utility Customer
Date
Signature of Utility Customer of Record (if different)
Date
(applicant)
Name of CSD Contractor/Partner Organization
Signature of 2nd Utility Customer of Record, if applicable Date
(CAPK)
CSD Form 081 (NEW 5-15)
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