Customer Authorization to Release Personally Identifying Information (PII)

By signing this form, I expressly authorize Jefferson County PUD #1 to release the personally identifying information listed below to a third party.

Customer Information

Account Number(Required)

Name on Account(Required)

First Last

Service Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

I authorize the release of my data as follows:

The type of data to be released (i.e. usage, payment, or billing history etc.) and the period in which the data covers (e.g. from January, 2014 through December, 2014) is further described below:(Required)

Name of Repicient/Business(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Manner in which data should be provided(Required)

(e.g. mail, email, pick up)

Date(s) in which this release is in effect(Required)

mm/dd/yyyy

This data release is at the request of, and on behalf of the Jefferson County PUD #1 Customer listed above, and as such, I agree to release and hold harmless Jefferson County PUD #1 from any liability, claims, demands, causes of action, damages or expenses resulting from 1) any release of information to the recipient noted above; 2) the unauthorized use of this information or data; and 3)from any actions taken by the recipient with respect to such information or data

Account Holder Identification(Required)

Max. file size: 128 MB.

Account Holder Signature(Required)

Date(Required)

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