[City of Neenah] Utility Consent Form

CONSENT TO DISCLOSE UTILITY CUSTOMER INFORMATION

This form was prepared by the Public Service Commission of Wisconsin as required by Wis. Stat. 196.137(4).

Account Holder / Business Phone Number

Service Address

Additional Addresses (if applicable)

Individual/Company/Property Mgmt Co to authorize access for account information.

Phone Number

Email Address

INFORMATION REQUESTED

The person or entity indentified above requests customer information, including billing and usage data related to water services provided by the utility. Such information includes your account balance, payment history and total use per billing period. The information provided by the utility may include any other information regarding your account contained in utility records.

CUSTOMER'S CONSENT

Your information is treated as private by the utility and can only be disclosed as permitted by Wis. Stat. 196.137. You are not required to authorize the disclosure of your customer information, and your decision not to authorize the disclosure will not affect your utility service.

By signing this form you acknowledge and agree that you are the customer(s) of record for this account and that you authorize the utility to disclose your customer information to the requesting entity listed on this form. This consent is valid until you terminate your service, or withdraw consent by sending a written request with your name and service address to: Neenah Utilities, 211 Walnut St., Neenah, WI, 54956. You may terminate this consent at any time.

Account Holder's Signature

First Name

Last Name

Choose how to sign

Draw Type

I agree to the terms and conditions listed above and consent to disclose my utility information to the requestor listed above.