OMB Control No. xxxx-xxxx

Energy Use Authorization Form

Id #





I hereby give permission to the electric, natural gas, fuel oil, and
propane (bottled gas including LPG) company or companies that provide
energy to me to provide information to the designated agent of the U.S.
Environmental Protection Agency for confidential use in connection with
their evaluation of energy savings achieved through the Home Performance
with ENERGY STAR program.

This authorization covers the following data for a period 13 months
before and 13 months after energy efficiency improvement were completed
on my home:

1) the total amount of fuels used by my household

2) the total price charged for fuels used by my household

Companies are authorized to provide this information by monthly periods
or by delivery date, whichever applies. An electronic copy of this
authorization may be accepted with the same authority as the original.

Printed Name: __________________________________________________

Signature : ________________________________ Date: _______________

Utility/Fuel Suppler Name	Account Number





















EPA Form 5900-184

The government estimates the average time needed to fill out this form
is 0.05 hours and welcomes suggestions for reducing this effort. Send
comments (referencing OMB Control Number) to the Director, Collection
Strategies Division, U.S. EPA (2822T), 1200 Pennsylvania Ave., NW,
Washington, D.C. 20460.

