CERTIFICATION UTILITIES MORATORIUM
TO:
(Electric or Natural Gas Company)
(Address)
DATE:
(Zip)
(State)
(City)
SUBJECT:
Request for Continuation of Services According to the N.C. Utilities Commission Order of
November 14, 1979, Amending Rules R12-10 & R12-11.
I
according to Rules R12-10 and R12-1 1.
I request that my electric/gas services be continued through March 31,
I certify that a member(s) of my household is either elderly (65 years of age and older) or disabled:
1 .
Elderly:
Name of Household Member
Age
Name of Household Member
Age
If disabled person in household, give following information:
Name of Household Member
Age
Description of Disability
Has he been certified as disabled by a governmental agency?
Yes
No If yes, list name of agency:
I certify that I cannot pay my electric/gas bill in full. Also, I certify that I cannot pay my past and current electric/
gas bill in six monthly payments. After paying my other monthly bills, I do not have the necessary resources.
2.
I certify that my household meets the eligibility requirements of the Low Income Energy Assistance Program.
3.
CERTIFICATION
I certify that the above information is true. I declare that to the best of my knowledge I am the only person in my
household who has applied for a continuation of services through March 31,
I
as provided in the November 14,
1979, order of the N.C. Utilities Commission. I am aware that I can be penalized by fine and/or imprisonment for making
false statements. Further, I am aware that while I may be eligible, the completion of this application does not entitle me to
any assistance under the Low Income Energy Assistance Program.
Applicant's Name (Print or Type)
(Applicant's Signature)
(Date)
Account Number (if known)
Service Address
I hereby certify that based on the information provided me by the above named applicant, that he is eligible for the
requested assistance.
(Local Administering Agency)
Distribution:
Original to Utility Company
1 Copy to Applicant
(Certifying Agent)
County File Copy
DSS-8118 (2/93)
(Date)
Economic Independence
