810 R.I. Code R. 810-RICR-10-00-1.21
(Name of Utility) | |
(Utility Customer Service Phone Number) | |
Customer | Account Number |
Address | Delinquent Balance |
Name of Person Notified | Intended Date of Termination |
AFFIDAVIT OF PERSONAL NOTICE | |
I, (Name of employee in print), hereby state under oath that on ( date) at ( time), I personally called at the above address and notified the person whose name appears above that service to the resident would be terminated unless within forty-eight hours satisfactory arrangements were made to pay the delinquent balance or otherwise settle the account unless the customer obtained review by the Division of Public Utilities and Carriers; that I informed the person to whom I spoke of the procedures for making such arrangements for obtaining a review by the Division; that I informed the person to whom I spoke of the availability of residential payment plans; that in my opinion the person to whom I spoke understood my communication and that during my call at the residence I neither observed nor was informed of any illness or other circumstance which would make termination of service a violation of the regulations of the Commission. | |
(Signature of Employee) | |
On, 20, the person whose signature appears above personally appeared before me and swore that the statements contained herein are true. | |
Notary Public | |
(Name of Utility) | |
(Utility Customer Service Phone Number) | |
Customer | Account Number |
Address | Delinquent Balance |
Name of Person Notified | Intended Date of Termination |
AFFIDAVIT OF PERSONAL NOTICE | |
I, (Name of employee in print), hereby state under oath that on ( date) at ( time), I personally visited the above address but was ( cross out inapplicable alternative) unable to gain admission/found no adult person therein/and that I left a written notice of company's intention to terminate service in the form approved by the Division of Public Utilities and Carriers prominently tacked or otherwise securely affixed to the front door. | |
(Signature of Employee) | |
On, 20, the person whose signature appears above personally appeared before me and swore that the statements contained herein are true. | |
Notary Public | |
(Name of Utility) | |
(Utility Customer Service Phone Number) | |
Customer | Account Number |
Address | Delinquent Balance |
Name of Person Notified | Intended Date of Termination |
AFFIDAVIT OF PERSONAL NOTICE | |
I, (Name of employee in print), hereby state under oath that on ( date(s)) at ( time(s)), I personally visited the above address, made personal contact with the customer or with a responsible adult found within the above address, but was unable to gain admission for purposes of disconnection of service. If the individual and I were not able to converse in a common language, I presented the individual with a multi-language utility service termination card as defined in § 1.2(A)(10) of this Part but I was still unable to gain admission for purposes of disconnection of service. | |
(Signature of Employee) | |
On, 20, the person whose signature appears above personally appeared before me and swore that the statements contained herein are true. | |
Notary Public | |
(Name of Utility) |
(Utility Customer Service Phone Number) |
[APPROPRIATE TERMINATION SYMBOL PURSUANT TO § 1.22 OF THIS PART (APPENDIX C)] |
This is a Utility Service Termination Notice. |
[in all languages required by § 1.5(D) of this Part] |
Translate Immediately! |
[in all languages required by § 1.5(D) of this Part] |
Our records indicate an unpaid balance on the account covering this residence. |
YOU MAY AVOID TERMINATION: |
Your utility service will not be terminated, on or before (same date as noted above), if satisfactory arrangements are made to pay this balance. As a first step, you must call our Customer Service Department at (telephone number) as soon as possible. |
If a satisfactory arrangement can not be agreed upon, you have the right to submit this matter to the Reviewing Officer of the Division of Public Utilities and Carriers at (401) 780-9700. If you are unable to reach a satisfactory arrangement over the telephone, you have the right to a hearing, which you must request, on whether the termination is justified. (NAME OF UTILITY) will not disconnect your service pending proceedings before a reviewing officer appointed by the Administrator of the Division of Public Utilities and Carriers. |
PROTECTION AGAINST TERMINATION: |
The Public Utilities Commission has Rules and Regulations that provide protection from termination of service for the seriously ill, handicapped and households in which all residents are at least 62 years of age. Please contact our Customer Service Department to determine eligibility. |
Under certain circumstances a customer may be protected from termination of service during the period between 12:01 AM November I'' and 11:59 PM April 15th. Please call our Customer Service Department to determine eligibility. |
If you or anyone currently and normally living in your house has a child under two (2) years old, we will not terminate or (TYPE OF UTILITY SERVICE) service, provided you also have a financial hardship. Please call our Customer Service Department to determine eligibility. |
LOW INCOME HEATING ASSISTANCE PROGRAM (LIHEAP) |
LIHEAP provides eligible customers with public energy assistance aid. Customers who may qualify should contact their local Community Action Program. |
RULES AND REGULATIONS |
A copy of the Rules and Regulations Governing Termination of Residential Electric, Gas and Water Utility Service are available for review at our office located at (address), (day) through (day) between the hours of ( start time) and ( end time). A copy of the Rules and Regulations is also available for review at the office of the Division of Public Utilities and Carriers located at 89 Jefferson Boulevard, Warwick, Rhode Island, Monday through Friday 8:30 AM to 3:30 PM. A copy of the Rules and Regulations may also be obtained via the Internet at http://www.ripuc.org/ |
(Name of Utility) | ||||||||||
(Utility Customer Service Phone Number) | ||||||||||
FINANCIAL HARDSHIP STATEMENT | ||||||||||
Name | Date | |||||||||
Address | Account Number | |||||||||
City/Town | ||||||||||
NOTE: If you are claiming Financial Hardship under the Rules and Regulations Governing the Termination of Residential Electric, Gas and Water Utility Services, please answer the following questions and return this form to the address shown on your bill within seven (7) days for an initial application and within forty (40) days if this is a renewal. DO NOT ENCLOSE THIS STATEMENT WITH YOUR BILL PAYMENT. | ||||||||||
INCOME INFORMATION | ||||||||||
Source of Gross Income: | Work | () Yes | () No | Amount | Week | Month | ||||
(for family or group) | SSI | () Yes | () No | Amount | Per Month | |||||
Welfare: | AFDC | () Yes | () No | Amount | Per Semi-Month | |||||
GPA | () Yes | () No | Amount | Per Week | ||||||
Other (Specify) | () Yes | () No | Amount | Per Two Weeks | ||||||
Total number in household | Number in household aged 62 or over | |||||||||
Number in household handicapped | ||||||||||
I, the undersigned, do hereby certify that the information provided is complete and the truth, to the best of my knowledge. | ||||||||||
Date | Signature | |||||||||
FOR OFFICE USE ONLY: | ||||||||||
Date Received | Accepted | Rejected | ||||||||
Company Representative | ||||||||||
Resubmittal Date | Resubmittal Waived | |||||||||
Company Rep. | ||||||||||
810 R.I. Code R. 810-RICR-10-00-1.21