79 1095 Form – Fill Out and Use This PDF

Pacific Gas and Electric Company	Original	Cal. P.U.C. Sheet No.	26268-E
San Francisco, California	Cancelling	Cal. P.U.C. Sheet No.
U 39

Electric Sample Form No. 79-1095

Authorization to Receive Customer Information or Act Upon a Customer's Behalf

Please Refer to Attached

Sample Form

Advice Letter No: 3015-E-A	Issued by	Date Filed	April 5,	2007
Decision No.	Brian K. Cherry	Effective	May 5,	2007
	Vice President	Resolution No.
1C1	Regulatory Relations

	AUTHORIZATION TO RECEIVE CUSTOMER INFORMATION
		OR ACT UPON A CUSTOMER’S BEHALF
	THIS IS A LEGALLY BINDING CONTRACT , PLEASE READ CAREFULLY
		(Please Print or Type)
I,
	NAME					TITLE (IF APPLICABLE
of					(Customer) have the following mailing address
	NAME OF CUSTOMER OF RECORD
							, and do hereby appoint
	MAILING ADDRESS	CITY			STATE	ZIP
			of
	NAME OF THIRD PARTY					MAILING ADDRESS
	CITY					STATE		ZIP

To act as my agent and consultant (Agent) for the listed account(s) and in the categories indicated below:

ACCOUNTS INCLUDED IN THIS AUTHORIZATION:

1.

SERVICE ADDRESSCITYSERVICE ACCOUNT NUMBER

2.

SERVICE ADDRESSCITYSERVICE ACCOUNT NUMBER

3.

SERVICE ADDRESS

CITY

SERVICE ACCOUNT NUMBER

(For more than three accounts, please list additional accounts on a separate sheet and attach it to this form)

INFORMATION, ACTS AND FUNCTIONS AUTHORIZED – This authorization provides authority to the Agent. The Agent must thereafter provide specific written instructions/requests (e-mail is acceptable) about the particular account(s) before any information is released or action is taken. In certain instances, the requested act or function may result in cost to you, the customer. Requests for information may be limited to the most recent 12 month period.

I (Customer) authorize my Agent to act on my behalf to perform the following specific acts and functions (initial all applicable boxes):

1.Request and receive billing records, billing history and all meter usage data used for bill calculation for all of my account(s), as specified herein, regarding utility services furnished by the Utility1.

2. Request and receive copies of correspondence in connection with my account(s) concerning (initial all that apply):

a. Verification of rate, date of rate change, and related information;

b. Contracts and Service Agreements;

c. Previous or proposed issuance of adjustments/credits; or

d. Other previously issued or unresolved/disputed billing adjustments.

3. Request investigation of my utility bill(s).

4. Request special metering, and the right to access interval usage and other metering data on my account(s).

5. Request rate analysis.

6. Request rate changes.

7. Request and receive verification of balances on my account(s) and discontinuance notices.

1 The Utility will provide standard customer information without charge up to two times in a 12-month period per service account. After two requests in a year, I understand I may be responsible for charges that may be incurred to process this request.

Page 1 of 2

Form 79-1095

Advice 2821-G-A/3015-E-A

April 2007

AUTHORIZATION TO RECEIVE CUSTOMER INFORMATION OR ACT ON A CUSTOMER’S BEHALF

I (CUSTOMER) AUTHORIZE THE RELEASE OF MY ACCOUNT INFORMATION AND AUTHORIZE MY AGENT TO ACT ON MY BEHALF ON THE FOLLOWING BASIS2 (initial one box only):

2If no time period is specified, authorization will be limited to a one-time authorization

One time authorization only (limited to a one-time request for information and/or the acts and functions specified above at the time of receipt of this Authorization).

One year authorization - Requests for information and/or for the acts and functions specified above will be accepted and processed each time requested within the twelve month period from the date of execution of this Authorization.

Authorization is given for the period commencing with the date of execution until ________________________(Limited in duration to

three years from the date of execution.) Requests for information and/or for the acts and functions specified above will be accepted and processed each time requested within the authorization period specified herein.

RELEASE OF ACCOUNT INFORMATION:

The Utility will provide the information requested above, to the extent available, via any one of the following. My (Agent) preferred format is (check all that apply):

Hard copy via US Mail (if applicable).

Facsimile at this telephone number:

Electronic format via electronic mail (if applicable) to this e-mail address:

I (Customer), __________________________________(print name of authorized signatory), declare under penalty of perjury under the laws of

the State of California that I am authorized to execute this document on behalf of the Customer of Record listed at the top of this form and that I have authority to financially bind the Customer of Record. I further certify that my Agent has authority to act on my behalf and request the release of information for the accounts listed on this form and perform the specific acts and functions listed above. I understand the Utility reserves the right to verify any authorization request submitted before releasing information or taking any action on my behalf. I authorize the Utility to release the requested information on my account or facilities to the above Agent who is acting on my behalf regarding the matters listed above. I hereby release, hold harmless, and indemnify the Utility from any liability, claims, demands, causes of action, damages, or expenses resulting from: 1) any release of information to my Agent pursuant to this Authorization; 2) the unauthorized use of this information by my Agent; and 3) from any actions taken by my Agent pursuant to this Authorization, including rate changes. I understand that I may cancel this authorization at any time by submitting a written request. [This form must be signed by someone who has authority to financially bind the customer (for example,

CFO of a company or City Manager of a municipality).]

AUTHORIZED CUSTOMER SIGNATURETELEPHONE NUMBER

Executed this	day of		at ______________________________________.
	MONTH	YEAR	CITY AND STATE WHERE EXECUTED

I (Agent), hereby release, hold harmless, and indemnify the Utility from any liability, claims, demand, causes of action, damages, or expenses resulting from the use of customer information obtained pursuant to this authorization and from the taking of any action pursuant to this authorization, including rate changes.

AGENT SIGNATURE			TELEPHONE NUMBER
COMPANY
Executed this	__________ day of ___________	_______
	MONTH	YEAR

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Form 79-1095

Advice 2821-G-A/3015-E-A

April 2007