NOTICE OF RIGHT TO REQUEST DISCLOSURE

Section 182.052, Texas Government Code, prohibits government-operated utilities from disclosing personal account information of a customer, or information relating to utility usage or amounts billed to or collected from a customer for utility usage, unless the customer requests that the government-operated utility disclose the information.

Please be aware that if you complete this form requesting disclosure of your information, you also have the right to revoke, in writing, that request for disclosure at any time beginning on the date CoLU receives such request. To exercise your rights to disclose your information, please complete the information requested on this form.

Account Information

Account Holder Name (Name on the Account)*

Utility Account Number (located on the left hand side of the bill)*

Account Holder Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Daytime Phone Number with Area Code*

Email Address

Please select one*

I hereby request disclosure of my information. I hereby revoke my previous request for disclosure and request to keep my personal information confidential.