Page 75

FY 2025 Low -Income Home Energy Assistance Program (LIHEAP) Client Home Energy Data Request Waiver

I,

, am the customer of record, the customer’s spouse, or an authorized agent/third party for the utility company and/or the fuel supplier that provides my household’s home energy. I authorize my utility provider and/or my fuel supplier to disclose my customer data (including, but not limited to, energy cost, consumption and billing data) to the Alabama Department of Economic and Community Affairs for the purposes of verification, analysis and reporting. I agree to hold harmless and/or release such companies from and against any claims, losses, demands, damages or liability of any kind caused by or allegedly caused by such disclosure.

The utility provider that provides electricity for my household is: Company name:

My account number is:

My household’s primary heating provider is: Company name:

My account number is:

Applicant Signature

Date

LIHEAP-101A

Revised 2024

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Page 75

Official source

FY 2025 Low -Income Home Energy Assistance Program (LIHEAP) Client Home Energy Data Request Waiver

I,

, am the customer of record, the customer’s spouse, or an authorized agent/third party for the utility company and/or the fuel supplier that provides my household’s home energy. I authorize my utility provider and/or my fuel supplier to disclose my customer data (including, but not limited to, energy cost, consumption and billing data) to the Alabama Department of Economic and Community Affairs for the purposes of verification, analysis and reporting. I agree to hold harmless and/or release such companies from and against any claims, losses, demands, damages or liability of any kind caused by or allegedly caused by such disclosure.

The utility provider that provides electricity for my household is: Company name:

My account number is:

My household’s primary heating provider is: Company name:

My account number is:

Applicant Signature

Date

LIHEAP-101A

Revised 2024