Required Signatures
This form must be signed by the person whose name appears on the electric utility account. ENERGY INFORMATION RELEASE:
The undersigned utility customer requests and authorizes the specified utility to release billing and usage information for the account
listed below to Bonneville Power Administration (BPA). With this authorization, BPA can request billing information for up to two
years pre-installation and two years post -installation. The utility customer also hereby releases the utility company from any and all
liability arising from or connected with providing this information.
A copy of the purchase receipt or installer’s invoice is included with this application.
Electric Utility
Customer Account #
Account Holder Name
Account Holder Signature
Date
By signing below, the installer certifies that this form and any accompanying documentation are complete and accurate, and that all
measures associated with this project were completed as of the signature date below. The signature certifies that the installer is
licensed, bonded, insured (or homeowner) and has been trained by the manufacturer of the installed product.
Installer Name
Installation Company
Contractor
Homeowner /Other
Installer Signature
Installer Phone #
Date
Basic authority for collecting this information is authorized by 16 U.S.C. §§ 832 et. seq., and 838 et. seq., pursuant
to Bonneville Power
Administration’s Conservation Program system of records established in 46 FR 31700. This information is primarily in tended to further,
but is incidental to the performance of, BPA’s overall Energy Efficiency Program, the objective of which is to acquire energy resources
through energy efficiency, to determine what cost-effective conservation and direct application renewable resources measures should be
installed or adopted under different circumstances, and to provide incentives for the installation of such measures. Other routine issues of
this information include: aggregation into a public database on energy efficiency; furnished to authorized personnel for installation/repair
of equipment; aggregated into a database for program publicity; and in some instances information regarding buildings will be made
available to subsequent purchasers of the buildings. Your disclosure of the requested information is voluntary; however failure to provide
requested information means that it will not be possible for you to participate in this BPA Energy Efficiency program.
PRIVACY ACT STATEMENT
Page 2 of 2
Pl
e
a
se Return This Form To:
City of Forest Grove Light and Power
P.O. Box 326
Forest Grove, OR 97116
Email: rooley@forestgrove-or.gov
VALID THROUGH 9/30/2019
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