Exhibit VI- Inability to Pay/Income Eligibility Form

Inability to pay/income eligibility form

IF YOU CAN'T PAY YOUR FULL BILLS AND NEED COLD WEATHER PROTECTION FROM UTILITY SHUT­OFF, fill out this form and return it to (name of utility) immediately.  The Cold Weather Rule provides that from October 15 through April 15 a utility cannot disconnect a residential utility customer if you enter into, and keep current with, a mutually agreed upon payment arrangement with the utility.

Fill out completely - please print

NAME _____________________________________________________________________________

SERVICE ADDRESS _____________________________________________________ APT#_____

CITY                STATE       ZIP               PHONE:  HOME                            WORK           

ACCOUNT NUMBER FROM YOUR BILL                                                       

TOTAL AMOUNT YOU OWE ________________________________

Total annual (yearly) household income $                     

Number of persons in household (include yourself) __

If you receive a form of public assistance for people with total household income at or below 50% of the state median household income level, please indicate that assistance program (for instance, Energy Assistance) on the line(s) below.  You may automatically qualify for Cold Weather Rule protection base on your eligibility for that program

____________________________    ___________________________

Payment Arrangements

I propose to pay my outstanding and future bills according to the following schedule of payments:

$               by (date)

$               by (date)

$               by (date)

$               by (date)

$               by (date)

 

By signing this form, I hereby acknowledge that I have received, read and understand the enclosed Notice of Residential Customer's Rights and Possible Assistance. I declare that the above information is true and correct. I give my permission to any energy provider or public assistance agency that serves me to exchange income and billing information for the purpose of program qualification.

Customer Signature: ___________________________________ Date: __________________

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