Form 5900-184 Homeowner Energy Data Release Form

OMB Control No. xxxx-xxxx

Energy Use Authorization Form

Id #

I hereby give permission to the electric, natural gas, fuel oil, and propane (bottled gas including LPG) company or companies that provide energy to me to provide information to the designated agent of the U.S. Environmental Protection Agency for confidential use in connection with their evaluation of energy savings achieved through the Home Performance with ENERGY STAR program.

This authorization covers the following data for a period 13 months before and 13 months after energy efficiency improvement were completed on my home:

1) the total amount of fuels used by my household

2) the total price charged for fuels used by my household

Companies are authorized to provide this information by monthly periods or by delivery date, whichever applies. An electronic copy of this authorization may be accepted with the same authority as the original.

Printed Name: __________________________________________________­­

Signature : ________________________________ Date: _______________

Utility/Fuel Suppler Name	Account Number

EPA Form 5900-184

The government estimates the average time needed to fill out this form is 0.05 hours and welcomes suggestions for reducing this effort. Send comments (referencing OMB Control Number) to the Director, Collection Strategies Division, U.S. EPA (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.