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2. Requesting Entity Name (if applicable)
4. Contact Person
6. Mailing Address
8. City
9. State
10. Zip Code
12. Phone
14. Fax
16. Email

18. 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 the Water Utility Department
    • Fax: 608-254-7785
    • Mail: P.O. Box 87, Lake Delton, WI 53940‐0087
20. Customer Account Number
22. Customer Phone Number
24. Service Address
26. City
27. State
28. Zip Code
30. Printed Customer(s) Name
32. Date
    Date
34. I agree*

    1. I agree

    By checking the "I agree" box, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

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36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field