Customer Privacy – Water Utility | The Village of Lake Delton, Wisconsin

In accordance with s. 196.137 Wis. Stats., the Lake Delton Utility Department does not release customer information, including account status and usage, without the consent of the customer. If you wish to have your customer information released to third parties you must provide written authorization to the Lake Delton Water Utility.

LAKE DELTON UTILITY DEPARTMENT

P.O. Box 87
Lake Delton WI 53940‐0087
www.lakedelton.org
(608) 254‐2558

CONSENT TO DISCLOSE UTILITY CUSTOMER INFORMATION
This form was prepared by the Public Service Commission of Wisconsin as required by Wis. Stat. § 196.137(4).

Requesting Entity Name (if applicable)
Contact Person
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Email
INFORMATION REQUESTED

The person or entity identified above requests customer information, including billing and usage data related to: all services provided by the Lake Delton Utility Department. Such information includes your account balance, payment history and total use per billing period. The information provided by the utility may include any other information regarding your account contained in utility records.

CUSTOMER’S CONSENT

Your information is treated as private by the utility and can only be disclosed as permitted by Wis. Stat. § 196.137. You are not required to authorize the disclosure of your customer information, and your decision not to authorize the disclosure will not affect your utility service.

By signing this form you acknowledge and agree that you are the customer(s) of record for this account and that you authorize the utility to disclose your customer information to the requesting entity listed on this form. This consent is valid until you terminate your service, or withdraw consent by sending a written request with your name and service address to the utility at the address specified at the top of this form. You may terminate this consent at any time.

Please complete this form and return it to the utility either by:
- Email: ldutility@lakedelton.org
- Fax: (608) 254‐7785
- Mail: P.O. Box 87, Lake Delton, WI 53940‐0087
CUSTOMER ACCOUNT NUMBER
SERVICE ADDRESS
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
PRINTED CUSTOMER(S) NAME
SIGNATURE OF CUSTOMER(S)
DATE SIGNED
Month
Day
Year
CUSTOMER PHONE NUMBER
Please complete separate consent forms for each utility account
Phone
This field is for validation purposes and should be left unchanged.