N.Y. Comp. Codes R. & Regs. tit. 16, Appendices, app 17
A MODEL LETTER AND FORM FOR DOCUMENTATION
OF INABILITY TO PAY UTILITY BILLS
UNDER 16 NYCRR 633.5
We have received an initial certificate of medical emergency, under which we must continue to provide you utility service for 30 days, starting ________ and continuing until the beginning of business on ________.
At the expiration of that period, we can, under the provisions of the Public Service Commission's regulations (633.5), terminate your utility service UNLESS the medical condition persists AND you do not have enough ready cash or income to meet your past-due and current utility bills and still meet your other necessary expenses such as food, housing, heating and medical treatment.
We enclose a form that you can use to provide the information we need to make a determination, as required by regulation, whether you are unable to pay past-due and current bills. We will continue to provide you utility service while we consider the information you provide.
If we determine that you have NOT demonstrated that you are unable to pay past-due and current bills, we will notify you in writing and inform you how you can seek review of our determination by the Public Service Commission.
If we determine that you have NOT shown that you have a financial hardship, we will offer you a deferred payment agreement, so that you can pay past-due bills and installments while you meet all current bills. And if you DO show a financial hardship, we will try to work out an arrangement so that you will not accumulate substantial past-due bills.
If you have any questions, you can call (local utility office/customer representative) at XXX-XXXX. If you are not satisfied with our response, you also can call the Public Service Commission between the hours of 9:00 a.m. and 4:45 p.m., Monday through Friday, at 1-800-342.3377.
Very truly yours,
Liquid assets, such as cash, bank savings or checking accounts, etc. should be listed.
Cash on hand $ ________
Bank checking account No. ________ Amt. presently in account $ ________
Bank savings account No. ________ Amt. presently in account $ ________
Name and address of banks ____________
Income information:
(week)
Source of Income: Work Yes________ No ________ Amt.________ (month)
SSI Yes________ No________ Amt ________ per mo.
Public or other Yes________ No________ Amt. ________ per 2 wks
Assistance
EXPENSES MONTHLY PAYMENT AMT. OWING
____________
Housing: Rent________ Own________
Food: Food Stamps: Yes________ No________
Medical expenses:
(incl. prescriptions)
Utility: (gas and electric)
Heating: (if not gas or electric)
Telephone:
Installment payments: (credit card)
Transportation:
Car expense: (loan, gas, etc.)
Education:
Other:
____________
I, the undersigned, do hereby certify that the above information provided is the truth, to the best of my knowledge.
____________
(signature)
____________
(date)
N.Y. Comp. Codes R. & Regs. tit. 16, Appendices, app 17