Utility Bill Information Release Consent
Name of Account Holder:
Service Address:
Utility Provider:
Account Number:
Party Authorized to Receive Information:
Contact Information of Authorized Party:
Purpose of Information Release:
Information to be Released:
Billing history
Utility usage data
Account status
Other
Duration of Consent (From):
Duration of Consent (To):
I authorize the release of my utility bill information as specified above.
Signature of Account Holder:
Date:
Additional Notes: