APS BILL ASSISTANCE AGREEMENT.PDF

Maricopa County — Formal (2020-12-09)

Extracted text (via pymupdf) 32850 characters

P.O. NO. 700777441
AGREEMENT BETWEEN APS AND MARICOPA COUNTY
FOR SPECIAL CRISIS BILL ASSISTANCE

This Agreement, effective the 1st of December, 2020 (“Effective Date”), is by and between
Arizona Public Service Company, an Arizona corporation, with offices at 400 North 5th Street,
Phoenix, Arizona 85004 (“APS”) and Maricopa County, administered by its Human Services
Department, with offices at 234 North Central Avenue, Phoenix, Arizona 85004 (“Contractor”).
Contractor and APS may each individually be referred to herein as a Party and collectively as the
Parties.

RECITALS

Whereas, APS has agreed to provide $500,000 (the Program Funds) to fund the Special
Crisis Bill Assistance Program for APS customers in crisis whose incomes are less than or equal
to 200% of the Federal poverty level guidelines; and

Whereas, APS enters this Agreement with Contractor to have Contractor administer and
disburse a portion of the Program Funds, as further described below.

Therefore, in consideration of the recitals set forth above, the respective agreements of the
Parties herein set forth, and other good and valuable consideration the receipt and sufficiency of
which are hereby acknowledged, the Parties agree as follows:

AGREEMENT

I.
TERM/TERMINATION

The term of this Agreement commences as of the Effective Date and terminates on
December 31, 2021 (the Term) unless terminated earlier by either Party in accordance with
the terms hereof. This Agreement is subject to A.R.S. § 38-511, the pertinent provisions
of which are incorporated here by this reference. Additionally, APS shall have the ability
to cancel this Agreement at any time during the term with 60 days written notice to
Counterparty.

II.
SCOPE OF SERVICES

A.
Program Coordination. The program provided for under this Agreement shall be referred
to as the Special Crisis Bill Assistance Program (or Program). On behalf of APS, the
Contractor will administer and disperse any Program Funds allocated to Contractor under
this Agreement to provide crisis bill assistance to eligible limited-income households and
individuals residing in APS’s service territory in accordance with the terms of this
Agreement. Contractor may rely upon the service territory maps available through APS’s
website (https://www.aps.com) to determine whether a household is located within APS’s
service territory.

B.
During the Term Contractor will perform the following services:

1.
Administer any Program Funds allocated to it and distribute them in
accordance with the terms hereof;
2.
Serve as a central point of contact for all activities reasonably necessary to
implement the services contemplated in this Agreement including, but not
limited to, remittance of payments, invoicing, tracking, auditing, and
reporting;
3.
To the extent possible, distribute Program Funds available to Contractor to
eligible limited-income customers by the end of the agreement Term;
4.
Recommend implementation timelines and oversee the development and
operation of specific Program procedures with input from, and subject to
APS review;
5.
Monitor and oversee all Program activities and prepare timely monthly
reports of such activities;
6.
Review and verify that all general and financial criteria for eligibility for
limited-income assistance as provided for in this Agreement are adhered to;
7.
Ensure that all Program related forms are completed and reviewed for
accuracy, including all audit forms used for customer qualification, and any
other verification calculations and documentation agreed upon in writing by
the Parties;
8.
Answer questions about the Program and resolve customer complaints
relating to the Special Crisis Bill Assistance from the Program. Issues
related to APS customer billing, account status, etc. will be relayed to APS
or the customer can contact APS directly;
9.
Coordinate with APS for promoting the Program (a) to customers involved
in the Special Crisis Bill Assistance process and (b) to local media,
including, presentations for city councils, county boards of supervisors and
low-income energy conferences;
10.
Fully utilize APS’s Electronic Agency Guarantee (EAG) portal. This
includes using the EAG portal to approve customers for Program funds and
enrolling any eligible customers into APS’s Energy Support (E-3) program
as the standard practice. Also, when making a guarantee a source for the
funds should be selected from the drop-down selections so it is possible to
track the source of funds.
11.
Perform such other administrative tasks as to which the Parties agree in
writing from time to time during the Term of this Agreement.

C.
Program Eligibility

1.
Other than the administrative fees discussed in paragraph VI.A, Program
Funds dispersed pursuant to this Agreement shall only be provided to, or on
behalf of, eligible limited-income individuals or households. To be eligible
to receive Program Funds, an individual and/or household must meet the
following income requirements and be experiencing a crisis situation as
defined below:

a. Income requirements. Eligible individuals and/or households shall have
a maximum gross household income less than or equal to 200% of the
Federal Poverty Level (FPL) as defined by the Arizona Department of
Economic Security (DES), as adjusted annually by DES. For purposes
of this Agreement a “Household” is defined as group of individuals in a
single residence for which energy is purchased in common.
b. Crisis situation. A customer is in a “Crisis Situation” if the customer
meets all of the following criteria:

i. must be a resident of Arizona;
ii. must not be a resident of an institution. Institutions include:
(a) hospitals;
(b) licensed domiciliary care facilities (family care homes,
homes for the aged, and family care homes for
developmentally disabled adults);
(c) intermediate care facilities;
(d) skilled nursing facilities or homes;
(e) alcohol and drug rehabilitation centers or treatment
program;
(f) dormitories;
(g) temporary protective facilities, such as domestic
violence shelters, etc.; or
(h) prisons;

iii. for a resident of public housing, the individual must have an
obligation to pay the utility bill directly to APS on an ongoing
basis; and
iv. the eligible individual must have had: (i) a loss or reduction of
income which places him/her within the range prescribed in
Section II.C.1(a), above; (ii) unexpected or unplanned expenses
that caused a lack of resources; or (iii) a condition has occurred
or exists that endangers the health or safety of the Household of
which the individual is a member; and

v. acceptable crisis situation documentation depends upon the
situation. As there are many crisis situations, the supporting
documentation is expected to vary. Documentation (digital or
paper) of the account provided by the customer is needed to give
the reason for the crisis and the context to the situation. Here are
some examples (not an exhaustive list) of documents that
provide proof of crisis:
(a) loss of employment or reduction of hours: letter of
termination from employer or paystub showing
reduction in hours;
(b) medical emergency or issue: doctor’s note or current
medical bill, ER discharge notes;
(c) unexpected expense documents such as:
i. bill related to the expense (car repair
bill/estimate);
ii. utilities shut off or delinquency notice;
iii. eviction notice; and
iv. other letter or document demonstrating the
additional financial burden; and
(d) victim of crime: police report or referral from a
domestic violence agency where individual participates.

2.
A Household or individual who meets all eligibility requirements set forth
above may receive up to $800 to cover a current or past-due APS bill but
may not receive Program Funds to pay APS bills incurred at former
residences. A Household or individual is eligible for bill assistance
payments twice during a 12-month period starting with the awarding of the
first bill assistance payment. The total amount of Program Funds awarded
to an individual and/or household during a 12-month rolling period cannot
exceed $800. Additionally, Program Funds may not be used to pay deposits.
3.
Customer Authorization. Prior to approving and submitting a customer for
assistance Contractor will ensure that the APS customer has accepted (via
signature, telephonic or digital approval) an approved consent form
allowing Contractor to access information from APS concerning the
customer’s relevant account information or other information needed to
assist the customer.

III.
REPORTING REQUIREMENTS

A.
Reporting Requirements

1.
To ensure that the Program Funds are promptly distributed to limited-
income customers within the Term that the funds are allocated, Contractor
is required to track and report monthly on several metrics and performance
measures as described in this Agreement.
2.
During the Term, Contractor will submit monthly reports to APS detailing
Program performance on a Spending Detail Report (Report). The Reports
must be sent to APS by the 20th of each month for the month prior.
3.
The Spending Detail Report must contain at a minimum the following
information:
a. An excel file that lists:
i.
Direct Services amount by customer1
ii.
Administrative fee amount by customer
iii.
Application date by customer
iv.
Customer name
v.
Customer address
vi.
Customer APS account number
vii.
Total
funds
distributed
for
Direct
Services
and
Administrative fees for the entire Term.

b. Contractor will send the Spending Detail Report via the APS secure Biscom
Email system.
4.
Failure to timely submit required Reports and other information that may
be reasonably requested from time to time pursuant to this Agreement may
be grounds for termination of this Agreement.

IV.
BILL ASSISTANCE ALLOCATION, PROMOTION, TRAINING AND AUDITS

A.
During the Term of this Agreement Contractor is eligible to receive a total of
$500,000 of Program Funds as described below:

1.
Contractor will invoice APS for $500,000 of Program Funds at the time of
execution of this Agreement. APS will provide those funds in accordance
with Section VI – Compensation/Taxes below.
2.
Contractor administrative costs will come from the Programs Funds.
3.
Contractor will distribute the Program Funds until they are gone.
Contractor will fully utilize the Electronic Agency Guarantee (EAG) portal
features as defined by APS in the EAG Agency contract to distribute
Program Funds.
B.
APS Program Promotion

1 These funds are the amounts paid to, or on behalf of, customers.

1.
APS will utilize its internal and external resources to provide a reasonable
amount of Program promotion. This will include posters, flyers,
newsletters, printing and other items as necessary to build customer
awareness regarding the availability of Program funds. APS will obtain
prior written consent before distribution of promotional materials using the
Contractor name and/or logo.
C.
APS Training Support for Contractor
1.
APS will utilize its internal and external resources to provide a reasonable
amount of training for Contractor personnel regarding the Program. This
will include in-person and/or Online based training and leave behind
materials.
D.
Auditing of records
1.
APS shall have the right to audit all books and records related to the
Program upon five (5) business days’ prior written notice to Contractor.
Notwithstanding requirements contained in this Agreement to the contrary,
Contractor may redact or withhold records that contain legally protected
confidential information pertaining to individual recipients of Program
Funds, such as social security numbers as well as attorney-client and work-
product communications and information.

V.
COMPENSATION/TAXES

A.
In exchange for providing the services contemplated in this Agreement, Contractor
is entitled to receive as its administrative fee 20% of each allocation of Program
Funds paid to it if it is fully utilizing the APS EAG system.
B.
Contractor shall be responsible for any taxes that may be levied, or imposed upon
it as a result of the transactions contemplated by this Agreement.
C.
Upon execution of this Agreement an original invoice(s), containing the purchase
order number # 700777441 provided for this transaction, should be submitted to
APS at:
payables@aps.com
michelle.lehman@aps.com
james.holbrook@aps.com
The invoice should include the P.O. number for this Agreement. Upon receipt of
the invoice APS shall have 15 business days to process the payment and provide
the funds to Contractor.

VI.
GENERAL TERMS AND CONDITIONS

A.
Handling of Personally Identifiable Information (PII) Information. For the purpose
of this Agreement PII includes any information that permits the identity of an
individual to be directly or indirectly inferred, including any information that is

linked or linkable to that individual. Examples of PII include, but are not limited to
name, address, customer account numbers, and addresses. Contractor should limit
its access to PII to the greatest extent possible. To the extent Contractor obtains PII
generated or received in connection with the Program from individual or household
recipients of Program Funds or from any other source, Contractor shall handle all
such PII in a confidential manner and have appropriate processes and procedures
in place for handling PII such in a secure and confidential manner. Upon request,
Contractor shall provide a description of such processes and procedures to APS.
B.
Warranties. Each Party warrants that the activities performed pursuant to or in
furtherance of this Agreement shall be performed in compliance with all applicable
laws, rules, regulations, codes, standards, ordinances and orders of regulatory
authorities having jurisdiction over the activities contemplated by this Agreement.
C.
Independent Contractor. The Parties will act as independent contractors and neither
Party will act as agent for or partner of the other Party for any purpose whatsoever,
and the employees of one will not be deemed employees of the other. Nothing in
this Agreement will grant to either Party, the right to make commitments of any
kind for or on behalf of the other Party without prior written consent of the other
Party.
D.
Limitation of Liability. Neither Party nor its respective officials, officers, directors,
departments, agencies, boards, committees, commissions, employees, volunteers,
agents, advisors, representatives, parents, affiliates, successors or assigns shall be
liable to the other Party for any indirect, consequential, special, punitive or
exemplary damages for any actions resulting from or arising out of this Agreement,
whether based on contract, tort (including, but not limited to, negligence), strict
liability, professional liability, contribution, or otherwise, provided, however, that
this limitation of liability shall not apply to: (a) the reciprocal indemnity obligations
of the Parties as set forth in section VI.E, Indemnification, below, or (b) losses
arising from a breach of the respective confidentiality obligations of the Parties
under Section VI.G, Confidentiality and Advertising.

E.
Indemnification. Each Party (as "Indemnitor") agrees to indemnify, defend, and
hold harmless the other Party (as "Indemnitee") from and against any and all claims,
losses, liability, costs, or expenses (including reasonable attorney fees) (hereinafter
collectively referred to as "Claims") arising out of the negligent performance of this
Agreement, but only to the extent that such Claims which result in
vicarious/derivative liability to the Indemnitee are caused by the act, omission,
negligence, misconduct, or other fault of the Indemnitor or its directors,
departments, agencies, boards, committees, commissions, employees, volunteers,
agents, advisors, representatives, parents, and affiliates.

F.
Insurance Coverages. Without limiting the Contractor’s indemnification
obligations, the Contractor shall provide and maintain the following insurance
coverages, using forms and insurers acceptable to APS, and require its contractors
and subcontractors who perform work with respect to the Program to carry the same
coverages:

1.
Workers’ Compensation insurance covering obligations imposed by
federal, state, and local statutes with jurisdiction over the Contractor’s (and
any of its contractor’s or subcontractor’s) employees and Employer’s
Liability insurance with limits of One Million Dollars ($1,000,000) per
accident for bodily injury by accident, One Million Dollars ($1,000,000)
per employee for bodily injury by disease and One Million Dollars
($1,000,000) and One Million Dollars ($1,000,000) policy limit for bodily
injury by disease;
2.
Commercial General Liability insurance with a combined single limit of
One Million Dollars ($1,000,000) each occurrence, and Two Million
Dollars ($2,000,000) general and products-completed operations aggregate.
The policy shall cover bodily injury, property damage, personal injury,
contractual liability, and products and completed operations; and
3.
Business Automobile Liability insurance with limits of One Million Dollars
($1,000,000) each occurrence with respect to the Contractor’s (and any of
its contractor’s or subcontractor's) vehicles, whether owned, hired, or non-
owned, assigned to or used in connection with performance of the Program.
4.
Data Protection/Cyber Liability insurance with limits not less than One
Million Dollars ($1,000,000) per claim and in the aggregate covering
liabilities resulting or arising from acts, errors, or omissions in rendering
Services or in connection with the Agreement. Coverage must include, but
not be limited to: damages Contractor is obligated to pay Company or any
third party associated with a Security Incident or associated with loss of PII
or Confidential Information; costs to notify individuals whose PII was lost
or compromised; and costs to provide credit monitoring and credit
restoration services to individuals whose PII was lost or compromised
regardless of cause (including, without limitation, Contractor’s negligence
or gross negligence and unlawful third party acts).
Such policy must provide coverage for wrongful acts, claims, and lawsuits
anywhere in the world and must be kept in force during the term of the
Agreement and for three (3) years after completion, cancellation or
termination of the Agreement.

All required policies held by Contractor, with the exception of the Worker’s
Compensation, shall name APS as an additional insured. Such policies shall
stipulate that the insurance shall be primary insurance and that any insurance
carried by APS shall not be contributory insurance. The Contractor and its insurers
providing the required coverages shall waive all rights of recovery against APS,
and their directors, officers, employees, and agents. In the event the Contractor
purchases insurance policies required by this Section that are not occurrence based
policies, Contractor shall either (a) maintain claims made policies for at least 3
years following termination of this Agreement, or (b) obtain extended discovery

periods for any claims made policies for at least three (3) years following
termination of this Agreement. Further, all policies required by this Section, except
for Workers’ Compensation, shall contain a severability of interest provision, and
shall not contain any commutation clause or any other provision that limits third
party actions over claims. Upon APS’s request, the Contractor shall provide
documentary evidence in a form and content reasonably acceptable to APS,
confirming to its reasonable satisfaction that the required insurance coverages have
been obtained and will remain in effect as required by this Section.
G.
Confidentiality and Advertising. All nonpublic information that one Party may
provide to another Party or that a Party acquires from any source in connection with
this Agreement shall be deemed to be confidential information (collectively called,
Confidential Information). Confidential Information includes, but is not limited to:
(a) customer specific information, including, without limitation, customer’s utility
bill information history; (b) any reports, specifications, know-how, strategies or
technical data, processes, business documents or information, market research or
other data, customer or client lists, and all other information concerning the
business and affairs of a Party that are owned, used, or possessed by or for the
benefit of a Party; (c) intellectual property of a Party; and (d) customer information
or materials obtained by a Party from a third party in connection with performance
of its obligations under this Agreement. Neither Party will not provide customer
confidential information or PII to the other Party without written customer consent.
The Contractor shall not make copies, reproductions, abstracts or excerpts of the
Confidential Information in whole or in part, except as authorized by APS or as
contemplated by this Agreement (including, without limitation, Contractor’s
production of Reports), nor use such information except as contemplated by this
Agreement. All copies, reproductions, excerpts or abstracts of Confidential
Information are deemed to be Confidential Information to the same extent as any
originals. Upon the expiration of the Term or the earlier termination of the
Agreement, the Contractor shall promptly return to APS all Confidential
Information and all copies thereof or other physical embodiments of the
Confidential Information.
The Contractor agrees that any and all of the Confidential Information shall be
maintained in confidence by the Contractor indefinitely. Confidential Information
may not be disclosed by the Contractor to any person other than the Contractor’s
personnel, employees or agents who require knowledge of the APS Confidential
Information in order to perform their respective obligations under this Agreement.
The Contractor further agrees that such Confidential Information shall be used
solely in connection with the Contractor’s performance of its obligations hereunder,
and for no other purpose, and that all persons to whom the Contractor discloses the
Confidential Information shall be advised of its confidential nature and of the
Contractor’s obligations of confidentiality and non-use under this Agreement. The
Contractor shall be responsible for any disclosure or use of Confidential
Information by persons to whom Contractor provided the Confidential Information
that is not in accordance with this Agreement.

The name and logo of APS or any of its affiliates shall not be used in any advertising
or other promotional context by the Contractor or its contractors or subcontractors
without the prior written consent of APS (which may be withheld by APS in its sole
discretion).
H.
Dispute Resolution/Attorneys’ Fees. If a dispute arises concerning this Agreement,
a meeting of the Parties shall be held within ten (10) business days after either Party
gives the other Party written notice of the dispute (the Dispute Notice). The Dispute
Notice shall set forth in reasonable detail the aggrieved Party’s position and its
proposal for resolution of the dispute. A representative of each Party who has
authority to resolve the dispute shall be in attendance at all meetings of the Parties
initiated in connection with a Dispute Notice. If the dispute is not resolved within
thirty (30) calendar days after the first meeting of the Parties, either Party is free to
use any other available remedy, including litigation. The Dispute Notice and 30-
day discussion period are conditions precedent to each Party’s right to resort to any
other method of dispute resolution, including litigation. A Party's failure to comply
with this Section shall entitle the other Party to recover its costs and reasonable
attorney fees in any judicial proceedings that circumvent this dispute resolution
provision. The prevailing Party in any proceedings instituted by either Party
regarding a dispute concerning this Agreement shall be entitled to recover its
reasonable attorney fees and taxable costs and expenses as allowed for and defined
under Arizona law.
I.
Severability. If any term or condition of this Agreement is held to be invalid, void,
or otherwise unenforceable by any court of competent jurisdiction, that holding
shall not affect the validity or enforceability of any other term or provision of this
Agreement, unless enforcing the balance of this Agreement would deprive either
party of a fundamental benefit of its bargain.
J.
Disclaimer of Third Party Beneficiaries. There are no persons or entities other than
those who are signatory to this Agreement such are intended to be benefited by the
terms contained herein and except to the extent a person or entity is entitled to
indemnification pursuant to Section VII.E, all third party beneficiaries are hereby
disclaimed.
K.
Survival. Termination of this Agreement shall not relieve either Party of any
obligation under this Agreement which expressly or by implication survives
termination of this Agreement, including its obligations under the following section
headings: Insurance Coverages, Indemnification, Limitation of Liability,
Warranties, Records and Auditing, Confidentiality and Advertising, Governing
Law, Dispute Resolution/Attorney's Fees.
L.
Entire Agreement. This Agreement contains the final and complete agreement
between the Parties with respect to the subject matter hereof and supersedes all
prior and contemporaneous conduct, agreements, statements, representations,
negotiations, course of conduct, course of dealing, and communications pertaining
to such matters, whether written or oral.
M.
Governing Law. This Agreement shall be governed by and interpreted in
accordance with the laws of the State of Arizona and of the United States without

giving effect to the doctrine of conflict of laws. This Agreement shall be deemed
made and entered into in Maricopa County, Arizona. Any suit to enforce this
Agreement shall be instituted only in the Superior Court of Maricopa County,
Arizona, or the Federal District Court for the District of Arizona, and such Courts
shall have the exclusive jurisdiction over any such suit or suits.
N.
Notices and Designated Representatives. All notices required to be given by this
Agreement will be given in person, by certified United States Mail, postage prepaid,
return receipt requested, by facsimile transmission, by reputable overnight delivery
service, or by email (confirmed by regular mail). All notices shall be deemed given
when received. Notices shall be directed to the Parties as follows:

If to APS:
Arizona Public Service Company
P.O. Box 53999
Mail Station 8028
Phoenix, Arizona 85072-3999
Designated Representative:
James Holbrook
Phone: (602) 250-2683
Cell: (623) 810-4419
Email: James.Holbrook@aps.com

If to Contractor:
Maricopa County Human Services Dept.
234 North Central Avenue
Phoenix, Arizona 85004

Designated Representatives:
Name, Title: Sandra Mendez, Assistant
Director, Community Services Division
Phone: 602-506-2316
Email: Sandra.Mendez@Maricopa.gov

Notices shall be effective: (a) on the date delivered by personal delivery, facsimile,
or electronic mail; (b) three (3) business days following the date deposited in the
United States mail; or (c) the next business day following delivery to a reputable
overnight delivery service. Notices and communications shall be delivered or
mailed to the Parties’ designated representatives named above.

Designated representatives of either Party may be changed at any time by providing
the other Party prior written notice of such change.
O.
Assignment. Neither Party will assign, transfer or otherwise dispose of its rights or
obligations under this Agreement or any interest therein, without the other Party's
prior written consent, which will not be unreasonably withheld, conditioned, or
delayed.
P.
Amendments and Modifications. This Agreement can be modified or amended
only by a writing signed by both Parties or their duly authorized agents. No course
of dealing or oral changes between the Parties will be effective or legally binding
as an amendment to this Agreement.
Q.
Records and Auditing. Contractor shall maintain accurate and complete records
relating to its performance of this Agreement, including, without limitation,
accounting records that support its reports to APS under this Agreement and
administration and disbursement of Program Funds. These records, with the

exception of attorney-client and work-product communications and information,
shall be retained by Contractor and be reasonably available for inspection and audit
by APS for four (4) years after completion or termination of this Agreement.
R.
Waiver. A Party’s failure or delay in enforcing the terms and conditions of this
Agreement or in insisting upon strict performance of any of the other Party’s
obligations shall not be interpreted as a waiver thereof. Waiver of any provision of
this Agreement by either Party shall only be effective if in writing and shall not be
interpreted as a waiver of any subsequent breach or failure under the same or any
other provision of this Agreement. No conduct, statement, course of conduct course
of dealing, oral expression, or other action shall be construed as a waiver.

IN WITNESS WHEREOF, this Agreement has been executed by the Parties as of the Effective
Date.

MARICOPA COUNTY
ARIZONA PUBLIC SERVICE COMPANY

_____________________________________
Clint Hickman, Chairman Board of
Supervisors
(signature)

_____________________________________
Date
(name)

Attested to:

_____________________________________
Fran McCarroll, Clerk of the Board
(title)

Approved as to Form:

_____________________________________
Deputy County Attorney Date
(date)

Attachment A – Customer Utility Information Release Authorization

UTILITY INFORMATION RELEASE AUTHORIZATION

By signing this form, I authorize Arizona Public Service Company (“APS”) to release my
historical and future utility bills, account information (such as, but not limited to, name, social
security number, service address, account number, balance, payment history, rate) and other
information concerning or related to energy consumption, costs and account information
necessary to enable my household to qualify for this and additional utility, food or shelter
assistance programs to any and all of the agencies/persons list on this form (“Authorized
Parties”). This release is granted in connection with my household’s request for and/or receipt of
assistance from the community agency listed below.

I understand and agree that the utility information released may be compiled and analyzed (both
on an individual and combined basis) by one or more of the Authorized Parties. I further
understand and agree that the utility information released, as well as any statistical or other
analysis, may be released by the Authorized Parties to a third party for reporting purposes related
to assistance received, and no information shall be made public in such a manner that my
dwelling or household occupants can be identified.

I further agree to release and hold harmless the above named utility provider(s) from: (i) any
claims, damages, liability or expenses resulting from the use or disclosure of information based
on this Authorization; (ii) the unauthorized use or disclosure of the information by any of the
Authorized Parties; and (iii) any actions taken by any of the Authorized Parties based on this
Authorization.

Authorized Parties:

Community Agency:

Name of agency determining assistance: Maricopa County administered by its Human Services
Department

Signature of Account Holder/Customer of Record ________________________

Print Account Holder/Customer of Record ______________________________

Service Address __________________________________________________

Account Number __________________________________________________

Date ___________________________________________________________