N.M. Admin. Code § 17.11.16.34
FINANCIAL CERTIFICATION FORM (VALID FOR 90 DAYS)
NOTE: You must complete this Financial Certification Form and a Medical Certification Form to continue receiving telecommunications service.
FINANCIAL SELF-CERTIFICATION (VALID FOR 90 DAYS)
I, [insert printed name] hereby certify that I am the person responsible for the charges for telecommunications service at [insert service address], that a seriously or chronically ill person, [insert name of seriously or chronically ill person], resides there, and that I do not have the financial resources to pay the charges for telecommunications service.
I understand that this certificate does not relieve me of the responsibility to pay my bill, and that I must submit another Financial Certification Form every 90 days.
I understand that if I provide false information, I could be denied medical emergency telecommunications services.
[customer's signature] [date]
[customer's social security number] [customer's telephone number] [service address]
[city] [ state] [zip code]
N.M. Admin. Code § 17.11.16.34