Utility Billing

OMB Control Number 1910-XXXX

U.S. DEPARTMENT OF ENERGY

Office of Weatherization and Intergovernmental Programs

Authorization to Obtain Energy Use Information

I hereby give permission to the electric and/or natural gas company that supply energy to me to provide information to the U.S. Department of Energy for confidential use in connection with studies of the programs managed by the Office of Weatherization and Intergovernmental Programs.

This permission is given for 1) the total amount of fuels used by my home and/or building, and 2) the total price charged for fuels used by my home and/or building. This authorization covers the period starting 36 months before the date of retrofit below to my home and/or building and for 36 months thereafter.

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

Signature: ___________________________________________ Date: ______________________

Printed Name: _____________________________________________________________________

Address: _________________________________________________________________________

Date of Retrofit: ______________________

Electricity provider: ____________________________________ Account #:__________________

Natural gas provider: ___________________________________ Account #:__________________

PRIVACY ACT STATEMENT

Section 6861 of title 42 of the United States Code and 10 C.F.R. § 440.25 authorize the collection of this information. The primary use of this information is to assist the Department of Energy in evaluating the energy and cost savings that result from the work of the Office of Weatherization and Intergovernmental Programs and to improve its future programs.

This information may be put to the following routine uses. It may be shared with other Federal agencies for statistical, auditing, or archiving purposes. It may be shared with law enforcement agencies investigating, prosecuting, or enforcing a violation of civil or criminal law or with other agencies for the purpose of implementing a statute, rule, or order. It may be shared with Congressional offices and auditing firms. And it may be released in response to a court subpoena or a request from appropriate parties pursuant to a discovery request or similar process.

You are not required to provide this information or sign this form. If you decide not to sign this form, it will not affect your eligibility for programs under the Office of Weatherization and Intergovernmental Programs.

Paperwork Reduction Act Burden Disclosure Statement

This data is being collected to measure energy efficiency efficacy. The data you supply will be used to help measure the success of the Department of Energy’s (DOE) Office of Weatherization and Intergovernmental Programs and allow the DOE to make improvements where necessary.

Public reporting burden for this collection of information is estimated to average (15 minutes) per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the Chief Information Officer, Records Management Division, IM-11, Paperwork Reduction Project (1910-XXXX), U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (1910-XXXX), Washington, DC 20503.

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