HENRY COUNTY PUBLIC SERVICE AUTHORITY
Privacy Policy and Release
The Henry County Public Service Authority will not release to anyone other than
staff, counsel for the Authority, a collection agent, those persons covered under §15.2-5124
of the Code of Virginia, or the undersigned, any information concerning your account,
payment history, address, telephone number, social security number, or other information
in the file except in response to a valid court order, valid FOIA request, or your direct
authorization. You hereby direct and authorize us to release information to the following
people:
Name Address __Password
1. ________________________________________________________
2. ________________________________________________________
3. ________________________________________________________
4. ________________________________________________________
Information may be released to the individuals/entities named above:
______1. In person, at the offices of the Henry County Public Service Authority, with a
photo identification.
______2. By telephone, with use of the password set forth by the name above.
______3. Both #1 and #2 above.
______4. I decline to list anyone on this privacy policy and release form. I do
not authorize any person other than those names listed on the
account to inquire or act on behalf of my account.
I have authorized the method of disclosure as indicated by my initials above.
Date:_________________________Signature:_______________________
This facility operates in a nondiscriminatory basis with regards to race, color, national origin,
religion, sex, familial status, age or handicap. Complaints of discrimination may be sent to the
U.S. Secretary of Agriculture, Washington, D.C. 20250.
Account # _____________
