Utility Billing Verification Form

UTILITY BILLING VERIFICATION FORM

Parties and Account Information

Account Number:     Service Address:

Recitals

WHEREAS, Client Name: is responsible for payment of utility services at the Service Address identified above; and

WHEREAS, Utility Company: maintains account records and billing information relevant to the account specified; and

WHEREAS, the parties wish to establish terms under which Utility Company will verify the accuracy of billed charges, provide supporting documentation, and permit limited disclosure of account information to effectuate reconciliation and payment.

Scope of Verification

The Utility Company shall, consistent with applicable law and internal policy, review and verify the billing records for the Billing Period specified below and provide documentation sufficient to substantiate billed charges, meter readings, applied credits, and payments posted to the account. Verification will include an examination of meter readings, billing calculations, applied adjustments, and any payment postings relevant to the period.

Billing Details to be Verified

Billing Period Start:    End:    Date Issued:

Total Amount Billed: $    Amount Paid: $    Outstanding Balance: $

Past Due Amount: $    Adjustments/Credits:

Previous Meter Reading:    Current Meter Reading:    Usage (units):

Documents provided with this request:
Previous bills Payment receipts Meter photos Other (see attachments)

Payment Terms for Verification Services

Verification Fee: $. This fee covers staff time and reasonable document retrieval costs.

Late Fee: per month on unpaid balances, and a minimum late fee of $.

Term and Termination

Effective Start Date: .    End Date (if applicable): .

Either party may terminate this verification engagement for convenience upon written notice to the other party delivered at least days prior to the effective termination date. Termination shall not affect obligations incurred prior to termination, including payment for services rendered.

Confidentiality

All non-public account information and supporting documentation exchanged under this form shall be treated as Confidential Information. Each party agrees to restrict disclosure to employees, contractors, or agents who have a need to know and who are bound by confidentiality obligations no less protective than those set forth herein. Confidential Information shall not be disclosed except as required by law, regulation, or valid legal process, provided the disclosing party gives prompt notice to the other party to permit a protective order or other remedy.

Governing Law; Entire Agreement

Governing Law: This form and any disputes arising under or relating to it shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of law principles.

Entire Agreement: This form constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior and contemporaneous understandings and agreements, whether written or oral. Any amendment must be in writing and signed by authorized representatives of both parties.

Certification and Authorization

By signing below, the undersigned Client certifies that the information provided is true, accurate, and complete to the best of the Client’s knowledge, and authorizes the Utility Company to disclose account records and billing information to the designated representative for the limited purpose of verification and reconciliation described herein. The Utility Company certifies that any information produced in response to this form is extracted from its official account records and represents its best, good faith effort to provide accurate billing documentation.

Additional Representations

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