Laserfiche WebLink
AUTHORIZATION TO RECEIVE CUSTOMER <br />INFORMATION OR ACT UPON A CUSTOMER’S BEHALF <br />† Information collected on this form is used in accordance with PG&E’s Privacy Policy. Page 1 of 2 <br /> The Privacy Policy is available at pge.com/privacy.Form 79-1095 <br />Advice 5058-G/7572-E <br />Automated Document, Preliminary Statement A April 2025 <br />THIS IS A LEGALLY BINDINGCONTRACT , PLEASE READ CAREFULLY <br />(Please Printor Type) <br />I, <br />NAME TITLE (IF APPLICABLE <br />of (Customer) have the following mailing address <br />NAME OF CUSTOMER OF RECORD <br />MAILING ADDRESS CITY STATE ZIP <br />, and do hereby appoint <br />o <br />f <br />NAME OF THIRD PARTY MAILING <br />ADDRESS <br />CITY STATE ZIP <br />To act as my agent and consultant (Agent) for the listed account(s) and in the categories indicated below: <br />ACCOUNTS INCLUDED IN THIS AUTHORIZATION: <br />1. <br />SERVICE ADDRESS CITY SERVICE ACCOUNT NUMBER <br />2. <br />SERVICE ADDRESS CITY SERVICE ACCOUNT NUMBER <br />3. <br />SERVICE ADDRESS CITY SERVICE ACCOUNT NUMBER <br />(For more than three accounts,please listadditionalaccountson a separatesheetand attach it to this form) <br />INFORMATION, ACTS AND FUNCTIONS AUTHORIZED – This authorization provides authority to the Agent. The Agent must thereafter <br />provide specific written instructions/requests (e-mail is acceptable) about the particular account(s) before any information is released <br />or action is taken. In certain instances, the requested act or function may result in cost to you, the customer. Requests for <br />information may be limited to the most recent 12 month period. <br />I (Customer) authorize my Agent to act on my behalf to perform the following specific acts and functions (initial all applicable boxes): <br />1. Request and receive billing records, billing history and all meter usage data used for bill calculation for all of my account(s), as specified <br />herein, regarding utility services furnished by the Utility <br />1. <br />2. Request and receive copies of correspondence in connection with my account(s) concerning (initial all that apply): <br />a. Verification of rate, date of rate change, and related information; <br />b. Contracts and Service Agreements; <br />c. Previous or proposed issuance of adjustments/credits; or <br />d. Other previously issued or unresolved/disputed billing adjustments. <br />3. Request investigation of my utility bill(s). <br />4. Request special metering, and the right to access interval usage and other metering data on my account(s). <br />5. Request rate analysis. <br />6. Request rate changes. <br />7. Request and receive verification of balances on my account(s) and discontinuance notices. <br />1 The Utility will provide standard customer information without charge up to two times in a 12-month period per service account. After two requests in a year, I understand I <br />may be responsible for charges that may be incurred to process this request. <br />FRPSOHWH FRPSOHWH <br />LQLWLDO <br />LQLWLDO <br />LQLWLDO <br />LQLWLDO <br />LQLWLDO <br />æêÚßìàãÛàåÞÜÚßåæãæÞàÜêȘãàäØëÜÚ ɆɈɋɇßØÙæëéàíÜȀìàëÜȰɄɂɂ <br />ãÜØêØåëæåȀ ɋɆɇɊɊ <br />ãÜØêÜêÜÜØëëØÚßÜÛãàêëæÝØÚÚæìåëêȥȥ <br /> ,QFOXGH$//3* (VHUYLFHDFFRXQWV JDV HOHFWULF <br />LQLWLDO <br />LQLWLDO <br />àëðæÝãÜØêØåëæå <br />ɃɄɅØàåëéÜÜëȀãÜØêØåëæåȀɋɆɇɈɈ <br />Gerry Beaudin City Manager <br />Docusign Envelope ID: 8C132635-A597-8F5D-8082-3EB7B8AE19BF