Exhibit VIII- Third Party Contact Form

Third Party Contact Form

Under some circumstances, a customer facing disconnection may need someone else to be responsible for communications with the utility.  The customer must consent to allow the utility to work with another person or party regarding the customer’s service.  That might be an individual or a community action agency or other local energy assistance provider.  The utility can create and send a form like the two-sided template below to obtain that customer consent.

(Text- Front of Form)

If you have been served a notice of proposed disconnection by your utility, you may want to alert a third party (friend, relative, church group, or community agency) that a disconnection notice has been issued to you. The third party will not be responsible to pay your bill. The third party does have the right to contact the utility and provide information or work out a payment arrangement on your behalf.

If you would like a third party to be notified of the potential disconnection, please complete the form on the back of this insert and return it to the utility.

(Text- Back of Form)

Customer Name ________________________

Account Number ________________________

Service Address _________________________

Home Phone ____________________

Work Phone ____________________

The utility has my permission to provide information to and accept information from the party named below:

Customer Signature


Date ___________________


Name of Third Party______________________________________

Third Party Address_______________________________________

City _________________State ___ Zip _____



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