CUSTOMER RECORD AND INFORMATION
RELEASE AND AUTHORIZATION
THE
UNDERSIGNED,
a customer of Duke Energy Florida, Inc d/b/a Duke Energy, does hereby grant
authority to Duke Energy, and any of its authorized representatives to release any and all information
concerning my account or other records, including, but not limited to, ail records relating to my payments (including
any delinquent payments or notices or returned checks for insufficient funds) for electric utility service, and
further, hereby releases Duke Energy from any and all liability related or in any way associated
with the release
of such information or
in any way related to the use made of such information by the party
to
whom the
information is provided.
This release is valid only for the person or entity to whom this authorization is granted;
is valid only for the period of time set forth below; and
is valid only for service on the account at the address or
addresses set forth below. Any other disclosure
is contrary to my wishes and the intent of this release and
authorization
.
I hereby allow this release and authorization and the information to be released by Duke Energy
to be transmitted electronically or via facsimile. By executing this release, I
hereby certify I
am
the account holder
and have authority to authorize Duke Energy
to disclose such information.
Customer Name:
(please provide full name)
Alternative Name:
Address:
Account(s) Number:
Last 4 digits of
Social Security Number ____________________________
(maiden, former, a/k/a)
THIS AUTHORIZATION IS DATED THIS DAY OF 20 , AND
IS
VALID FOR A PERIOD OF 90 DAYS THEREAFTER. ANY DISCLOSURE OF INFORMATION
MADE DURING THAT PERIOD SHALL BE DEEMED AUTHORIZED.
CUSTOMER SIGNATURE
The Customer has provided proof of identity (government issued photo id or social security card).
Agency's
Signature
