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