Fillable Consent to disclose utility customer data (Otter Tail Power Company)

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Consent to disclose utility customer data (Otter Tail Power Company)

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Consent to disclose utility customer data
All requested information must be provided for the consent to be valid.
TO BE COMPLETED BY THE DATA RECIPIENT
Utility Name and Contact: Otter Tail Power Company
Physical and Mailing Address: 216 S Cascade St Fergus Falls, MN 56537
PO Box 496 Fergus Falls, MN 56538-0496
Phone: 800-257-4044
For additional information, including Otter Tail Power Company’s privacy policy, visit www.otpco.com
By signing this form, you allow Otter Tail Power Company to give the following information to:
Organization/Trade Name:
Contact Name (if available):
Physical and Mailing Address:
Phone:
This organization will receive the following customer data:
Information from your electric service meter collected by Otter Tail Power Company
Information regarding your participation in renewable energy,
demand-side
management,
load management, energy efciency or other programs offered by Otter Tail Power Company
Other (specify) .
DATA COLLECTION
PERIOD
The relevant timeframe associated with the requested data is from
/ / and will:
End on / /
Be effective until terminated by you.
You may terminate this consent at any time by sending a written request with your name and service
address to Otter Tail Power Company.
Page 1 of 2
CUSTOMER DISCLOSURES
*** Customer data can provide insight into activities within the premises receiving utility service.
Otter Tail Power Company may not disclose your customer data except (1) if you authorize the
disclosure, (2) to contracted agents that perform services on behalf of Otter Tail Power Company, or
(3) as otherwise permitted or required by laws or regulations.***
***You are not required to authorize the disclosure of your customer data. Not authorizing disclosure
will not affect your utility services.***
***You may access your standard customer data from Otter Tail Power Company without any
additional charge.***
***Otter Tail Power Company will have no control over the data disclosed pursuant to this consent,
and will not be responsible for monitoring or taking any steps to ensure that the data recipient
maintains the condentiality of the data or uses the data as authorized by you. Please be advised that
you may not be able to control the use or misuse of your data once it has been released.***
***In addition to the Customer Data described above, the data recipient may also receive the
following from Otter Tail Power Company: your name; account number; meter number; utility type;
service address; premise number; premise description; meter read date(s); number of days in the
billing period; utility invoice date; base rate bill amount; other charges including base rate and non-
base rate adjustments; taxes; and invoice total amount. Otter Tail Power Company will not provide any
other information, including Personally Identiable Information such as your Social Security Number or
any nancial account number to the data recipient through this consent form.***
TO BE COMPLETED BY THE CUSTOMER
PLEASE READ THE ABOVE CUSTOMER DISCLOSURES BEFORE SIGNING THIS FORM
By signing this form, you acknowledge and agree that you are the customer of record for this
account and that you authorize Otter Tail Power Company to disclose your customer data as specied
in this form.
CUSTOMER ACCOUNT NUMBER
SERVICE ADDRESS
PRINTED NAME
SIGNATURE OF CUSTOMER OF RECORD DATE SIGNED
Page 2 of 2
2918797
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Consent to disclose utility customer data (Otter Tail Power Company)

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Completed 22 July 2021

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