Snohomish County PUD 2/23/2023 - Laserfiche WebLink

This consent form will allow Snohomish PUD to release customer infoitnation as indicated below to a third party for non- PUD business purposes. To authorize third party disclosure, the customer must complete this document in its entirety, and the utility must verify that the individual providing consent matches the name, service address and account number of the customer of record in the utility's customer information system. CUSTOMER INFORMATION: Account Number(s): 201770179, 203311220 (Main Library, Everett Municipal Building) Meter Number(s): d 1175200, 111656+68 t 00014t)4'4&/ t OOP r Atli < ! bp Name on Account: City of Everett Name of Representative (ifa business): Neil Bavins, Resource Conservation Program Mgr Service Address: 2702 Hoyt Avenue, 2930 Wetmore Avenue Telephone number: 360-309-0075 Email address (ifapphcable): nbavins@everettwa.gov AUTHORIZATION: I authorize the release of my customer information as follows: Type of information to be released (for example, usage or payment history, payment, contact information): Energy usage/cost, billing history and relevant data Period which the information covers: January 1, 2020 through December 31, 2024 Name of recipient/business: Automated Energy Inc. Address: 4100 Perimeter Center Drive, Suite 115, Oklahoma City, OK 73112 Telephone number or contact information: 405-601-7500 FAX: 405-601-7503 Manner in which information is to be provided (mail, email, pick-up, etc.): SFTP Date(s) for which this release is in effect: (TBD) through December 31, 2024 RELEASE: This consent for information release is at the request of, and on behalf of the customer listed above. Therefore, the Customer agrees to release and hold hainnless Snohomish PUD from any liability, claims, demands, causes of action, damages or expenses resulting from: 1) any release of information to the recipient authorized above' (2) the unauthorized use of such information by the recipient; and (3) any actions tak- e recipient with respect to such information. I s - Account Holder Signature: Date: /60 11% Or Authorized Representative : y gn: . i •ve, I attest under penalty of perjury that I have the authority from the holder of the account to authorize the release of information set forth above. This consent form must be signed by the customer or authorized representative listed above, and may be submitted by US Mail, or may be scanned and sent by electronic mail. If scanned and sent by electronic mail, the customer agrees that the scanned image will be considered the valid authorization. For Internal Use: Verified By: Date: Time of Day Pilot Customer Participant Agreement -- Draft Execution Final Dec 2, 2022 6 of 6