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[Insert Utility Contact Information Here]
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).
Requesting Entity Name (if applicable) ___________________________________________________
Contact Person_________________________________________________________________
Mailing Address________________________________________________________________
Phone_(_____)____________ Fax_(_____)____________ Email_________________________
INFORMATION REQUESTED
The person or entity identified above requests customer information, including billing and usage data
related to: □ electric; □ gas; □ water; or □ all services provided by the ulity. Such informaon
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 the utility at the address
specified at the top of this form. You may terminate this consent at any time.
Please complete this form and return it to the utility either by:
Email:________________________________________________________________________
Fax:_(_____)__________________________________________________________________
Mail:________________________________________________________________________
CUSTOMER ACCOUNT NUMBER________________________________________________________
SERVICE ADDRESS____________________________________________________________________
PRINTED CUSTOMER(S) NAME_________________________________________________________
SIGNATURE OF CUSTOMER(S) __________________________________________________________
DATE SIGNED____________________ CUSTOMER PHONE NUMBER_(_____)___________________
Please complete separate consent forms for each utility account.
UTILITYBILL@OSHKOSHWI.GOV
PO BOX 1130 Oshkosh WI 54903-1130