Important Notice:

With my signature below, I authorize the above named utility provider(s) (indicated by box checked) to release my historical and future utility bills, account information (such as but not limited to name, service address, account number, balance, payment history) and other information concerning or related to energy consumption and costs to any and all of the agencies/persons listed on this form ("Authorized Parties").

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This release is granted in connection with my household's request for and/or receipt of assistance from the community agency listed below. I understand and agree that the utility information released may be compiled and analyzed (both on an individual household and combined basis) by one or more of the Authorized Parties.  I further understand and agree that the utility information released, as well as any statistical or other analysis, may be released by the Authorized Parties to a third party for reporting purposes related to assistance received, and no information released shall be made public in such a manner that my dwelling or my household occupants can be identified.

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I further agree to release and hold harmless the above named utility provider(s) from: (i) any claims, damages, liability or expenses resulting from the use or disclosure of information based on this Authorization; (ii) the unauthorized use or disclosure of the information by any of the Authorized Parties; and (iii) any actions taken by any of the Authorized Parties based on this Authorization.