Personally Identifying Information Form

Customer Authorization to Release Information

By signing this form, I expressly authorize Jefferson County Public Utility District No. 1 to release the personally identifying information (PII) listed below to a third-party.

Account Number

Service Address

Phone Number

Email

(if applicable)

I authorize the release of my customer data as follow:

The type of data to be released (i.e. usage or payment history, payment, etc.) and the period in which the data covers (e.g. from January, 2024 through June, 2024) is further described below:

Name of Recipient/Business:

Address:

Email

(if applicable)

Phone Number

Manner in which data should be provided (mail, email, pickup):

Date(s) in which this release is in effect:

Signature Required

This data release is at the request of, and on the behalf of the Jefferson County Public Utility District No. 1 customer listed above, and as such, the I agree to release and hold harmless Jefferson County Public Utility District No. 1 from any liability, claims, demands, cause 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.

Signature

Date