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

Name on Account(Required)
Service Address(Required)

I authorize the release of my data as follows:

(e.g. mail, email, pick up)
Date(s) in which this release is in effect(Required)
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