EIA-457A Household Survey Authorization

Authorization Form

2015 Residential Energy Consumption Survey

Sponsored by the U.S. Energy Information Administration

U.S. Department of Energy, Washington, DC

This authorization form covers information for each energy source used in the household identified below, for the period from September 1, 2014 through April 30, 2016.

Name:_______________________________________________

Address: _____________________________________________

City: ________________________________________________

State: _________ ZIP Code: _____________________

Case ID: ______________________________________

I hereby give permission to the company (companies) below to provide information to the U.S. Energy Information Administration or its designee for confidential use in connection with the 2015 Residential Energy Consumption Survey. A photocopy of this form may be accepted with the same authority as the original.

__________________________________________________

Please print name of authorizing person

_________________________________________________

Signature of authorizing person

Print full name of energy supplier for each energy source.

__________________________

Energy Source

__________________________

Energy Source

__________________________

Energy Source

__________________________

Energy Source

__________________________

Energy Source

__________________________

Energy Source

Form EIA-457A

OMB No.: 1905-0092 Expires: XX/XX/XXXX