Name: _________________________________________
Account #: ______________
Address: __________________________________________________________________
__________________________________________________________________
Phone: (H)____________________________ (C)________________________________

I/We, myself/ourselves, my/our heirs executors, administrators, successors and assigns do hereby release, acquit, and forever discharge Alger Delta Cooperative Electric Association and their present and future successors, employees, affiliates, assigns, and all other persons, firms or corporations who might or are now, or in the future be liable for any and all claims, demands, damages, costs, expenses, attorneys fees, actions and causes of action of whatever kind or nature whether known or unknown which I/we now have or may hereafter have, or sustain on account of, or in any way growing out of, or resulting from any use whether lawful or not, whether in business or trade or for personal purposes, of this device identified as a Kill-A-Watt EZ watt meter.

I, the undersigned, understand that I am borrowing a Kill-A-Watt EZ watt meter, an electrical device, from Alger Delta Cooperative Electric Association. I agree to read instructions prior to use and to abide by the instructions during use. I agree that I am responsible for the care, use, and return of this device. Further, if for any reason, whether my fault or no fault of my own, this device is damaged, lost, stolen or destroyed or for any reason or no reason is not returned to Alger Delta Cooperative Electric Association within 45 days from the date shown below, I authorize Alger Delta Cooperative Electric Association to charge a non-refundable replacement fee of $40 to my electric energy account.

Signature: ___________________________________________________________
Device Number: ________________________________
Date Loaned: ________________________________
Date Returned: ________________________________