Utility Consumption Information Release WX22

State of Nebraska Weatherization Assistance Program
Utility Consumption Information Release

WX22
Name*

First NameMiddle NameLast Name
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
UTILITY COMPANY INFORMATION
I certify that I am the owner/tenant of the property at:
Address*
and I hereby authorize the following utilities to release information regarding my fuel bills, both past and future, to: Northeast Nebraska CommunityActionPartnership
the Nebraska Energy Office (NEO) and the U.S. Department of Energy (DOE
Natural Gas Company/Supplier
Natural Gas Account Number
Electric Company/Supplier
Electric Company Account Number
Propane/Fuel Oil Company/Supplier
Propane/Fuel Oil Account Number
Click to attach Fuel Bill for each company/supplier listed above

Cancelof
SIGNATURES
I understand that all information related to this application is confidential and will only be used to provide data for the above named agencies and no information obtained through this release will be made public in such a manner that the dwelling or occupants can be identified.
Household Applicant Name*
Utility Account Holder Name*
Household Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Utility Account Holder’s Signature

Clear
Date

MonthDayYear
Date
This material was prepared with the support of DOE, Low Income Weatherization Assistance Program Grant. However, any opinions findings conclusions or recommendations expressed herein are those of the author and do not necessarily reflect the views of DOE.
Should be Empty:

State of Nebraska Weatherization Assistance Program

Utility Consumption Information Release

UTILITY COMPANY INFORMATION

SIGNATURES