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Customer Authorization for Disclosure of Customer Information

Permission is hereby granted to Utility Management Services, Inc. (6317 Oleander Dr.
Ste C, Wilmington, NC 28403) to act as my/our agent and to obtain copies of billing history and
Customer Service Records, including on-line access to account information, and to initiate rate
change requests on the Customer’s behalf for the account number(s) shown below.

This authorization will remain in effect for a period of 60 months after the date of
signature of this authorization, and may also be revoked at any time by notifying my power
provider in writing of such revocation.

Signature: _________________________ Date: ___________________
Name: ____________________________ Title: ___________________
EIN: _______________________________________________________
Customer Legal Name _________________________________________
Contact Ph: ___________ Fax: ___________ Email: _________________
Mailing Address: ______________________________________________

Provider: _______________________________________________

Account Number (attach additional sheets if Name as it appears on bill
necessary)

Rev. 05/2019