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Maryland People’s Counsel Resource Guide Resource Guide Utility Bill Assistance in Baltimore County Contents 1-2-3: Utility Bill Assistance at a Glance.......................... Page 1 Electric and Gas Utility Programs.................................... Page 2 Energy Assistance Programs - OHEP .............................. Page 3 - Maryland Energy Assistance Program (MEAP) - Electric Universal Service Program (EUSP) - EUSP Weatherization - Appliance Replacement and Repair Documents Needed and Income Guidelines................... Page 4 Energy Assistance Programs - DSS............................... Page 5 - Emergency Assistance to Families with Children (EAFC) - Flex Funds - Welfare Avoidance Grant (WAG) - Special and Local Funds Offices on Aging............................................................... Page 5 Department of Social Services (DSS) Centers................. Page 6 Energy Assistance - Other Funds.................................... Page 7 - Fuel Funds - Federal Emergency Management Assistance (FEMA) - Private Charities Conservation and Housing Programs.............................. Page 8 Tax Credits....................................................................... Page 9 Telephone Bill Assistance............................................... Page 10 Utility Bill Assistance Flowchart....................................... Page 11 Complaint Form............................................................... Page 12 13 & 14 Physician’s Certification.................................................... Page 15 Maryland People’s Counsel 6 St. Paul Street, Suite 2102 Baltimore, MD 21202 410-767-8150 1-800-207-4055 MD Relay Services: 711 Web Site: www.opc.state.md.us

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Page 1: Maryland People’s Counsel Resource Guidemsa.maryland.gov/megafile/msa/speccol/sc5300/sc5339/... · 2005. 9. 1. · gency (i.e., defective or inoperable furnace), he or she should

Maryland People’s Counsel

Resource GuideResource GuideUtility Bill Assistance inBaltimore County

Contents

1-2-3: Utility Bill Assistance at a Glance.......................... Page 1

Electric and Gas Utility Programs.................................... Page 2

Energy Assistance Programs - OHEP.............................. Page 3- Maryland Energy Assistance Program (MEAP)- Electric Universal Service Program (EUSP)- EUSP Weatherization- Appliance Replacement and Repair

Documents Needed and Income Guidelines................... Page 4

Energy Assistance Programs - DSS............................... Page 5- Emergency Assistance to Families with Children (EAFC)- Flex Funds- Welfare Avoidance Grant (WAG)- Special and Local Funds

Offices on Aging............................................................... Page 5

Department of Social Services (DSS) Centers.................Page 6

Energy Assistance - Other Funds.................................... Page 7 - Fuel Funds- Federal Emergency Management Assistance (FEMA)- Private Charities

Conservation and Housing Programs.............................. Page 8

Tax Credits....................................................................... Page 9

Telephone Bill Assistance............................................... Page 10

Utility Bill Assistance Flowchart....................................... Page 11

Complaint Form............................................................... Page 1213 & 14

Physician’s Certification.................................................... Page 15

Maryland People’s Counsel6 St. Paul Street, Suite 2102

Baltimore, MD 21202410-767-8150

1-800-207-4055MD Relay Services: 711

Web Site:www.opc.state.md.us

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1-2-3 Utility Bill Assistance at a Glance

1. Apply for MEAP and EUSPenergy assistance

Limited income customers may be eligible for twostate programs that can help pay off utility bills.Youcan apply for these programs on the same applica-tion.

Maryland Energy Assistance Program (MEAP)distributes funds for gas, oil, electricity and otherhome heating and cooling bills to limited incomeindividuals and families.

Electric Universal Service Program (EUSP) is anew program that helps low-income electricity cus-tomers pay their current and past due electricitybills. Some customers who are not eligible forMEAP are eligible for EUSP.

Enrollment in these programs is not automatic. Youmust meet eligibility requirements and apply in per-son at a local assistance agency. Local assistanceoffices are listed in this guide. For locations in othercounties, contact the Maryland Office of HomeEnergy Programs (1-800-352-1446).

Important! If you have received a shut-off noticeand someone in the home is seriously ill or needslife support equipment, contact the utility immedi-ately. You must send a physician’s certificationabout the condition to the utility. A copy of thephysician’s certification is included in this packet.

The Office of People's Counsel is here to help you. Contact our office if you are having problems resolving adispute with your utility, need help getting energy assistance or if you have questions about the law, regulationsor process for filing consumer complaints.

2. Ask about other energy assistance funds

You may be able to get additional assistance from alocal Fuel Fund, or other state or local programs.Information about some of these funds is included inthis packet. Ask for a phone number or referral whenyou apply for energy assistance.

3. Try to work out a paymentarrangement

You may still owe money to the utility even if youreceived energy assistance. Also, if your income ishigher than the guidelines, you will not be eligible toreceive EUSP or MEAP funds.

You should contact the utility to work out a reason-able payment plan for the past-due amount. If youtry to work out a payment arrangement and are notsuccessful, contact the Public Service Commissionat 410-767-8028 to make a complaint. The PSCcomplaint form is enclosed in this packet.

You may be able to get help from local agencies thatwork with senior citizens, persons with disabilitiesor faith-based organizations, particularly if you havehad a household emergency such as a job loss, jobinjury, or high medical bills. Ask your local assis-tance agency about these programs.

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BALTIMORE COUNTY RESOURCE GUIDE

Electric and Gas Utilities

Electric

BALTIMORE GAS AND ELECTRIC COMPANYP.O. BOX1475BALTIMORE, MD 21203-1475410-685-01231-800-685-0123www.bge.com

Natural Gas

BALTIMORE GAS AND ELECTRIC COMPANYP.O. BOX 1475BALTIMORE, MARYLAND 21203-1475410-685-01231-800-685-0123www.bge.com

BUDGET BILLING (EVEN MONTHLY PAYMENTPLAN). The utilities offer an even monthly payment planfor customers, which allows the customer to pay the sameamount every month. The monthly payments are based on acustomer's expected annual usage. This amount is changedperiodically if the customer uses more or less gas or electric-ity than anticipated. The program does not eliminate monthlychanges in the bill, but it does smooth them out. This pro-gram is especially helpful if a customer wants to maintain afixed amount of expenses throughout the year.

BILL EXTENDER PLAN. The utility is required to adjusta customer's bill due date if he or she receives monthlyincome through Social Security or through a government-sponsored assistance program. This can help avoid late pay-ment fees, since a customer can pay the bill after receipt ofhis or her monthly income.

UTILITY SERVICE PROTECTION PROGRAM(USPP). USPP is a program designed to protect householdsfrom utility service terminations during the winter. The pro-gram, established by the Public Service Commission, isavailable to MEAP recipients, and provides assistance, suchas reconnection fee and security deposit waivers, to eligibleoff-service customers. A customer must enroll in the compa-ny's even monthly payment plan and apply the MEAP grantto the heating company bill.

BGE CUSTOMER ASSISTANCE MAINTENANCEPROGRAM (CAMP). BGE customers who are eligible forMEAP and who participate in USPP may qualify for up to$144 a year in credits on their BGE bills. A customer maybe able to get $12, $9 or $7 per month in bill credits for eachmonth a bill is paid in full by the due date.

DISPUTES WITH THE UTILITY. A customershould contact the utility first to request information orresolve a dispute. If it is not resolved, a customer mayfile a complaint:

PUBLIC SERVICE COMMISSION OF MARYLAND6 ST. PAUL STREET, 12th FLOORBALTIMORE, MARYLAND 21202410-767-80281-800-492-0474www.psc.state.md.us/psc

Electric and Gas Utility Programs

Energy Assistance - U

tility

2

PAYMENT ARRANGEMENTS WITH THE UTILITY.A customer who is having difficulty paying gas or electricbills should ask the utility about a payment plan to pay past-due bills over time. A deferred payment plan should take acustomer's individual circumstances into account, includingother available assistance, income and the amount owed. Ifthe utility will not work with the customer to establish rea-sonable payment arrangements, the customer may contactthe Public Service Commission’s Office of ExternalRelations to request help mediating acceptable paymentarrangement terms:

PUBLIC SERVICE COMMISSION OF MARYLAND6 ST. PAUL STREET, 12th FLOORBALTIMORE, MARYLAND 21202410-767-80281-800-492-0474www.psc.state.md.us/psc

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MARYLAND ENERGYASSISTANCE PROGRAM (MEAP)

MEAP is an energy assistance program that helps low-income households with their heating bills. The program,administered by the Office of Home Energy Programs(OHEP), is available to homeowners and renters whomeet the income requirements and heat with electricity,gas, oil, propane, wood or other fuels. The program pro-vides an annual grant that varies depending on householdsize, household income and type of home heating source.

ELECTRIC UNIVERSALSERVICE PROGRAM (EUSP)

EUSP is a new program which helps low-income electrici-ty customers pay their electricity bills. The program isavailable to homeowners and renters who meet theincome requirements, which are the same as the guide-lines for MEAP. Some customers, who are not eligiblefor MEAP because they are in subsidized housing, may beeligible for EUSP. The program includes bill assistance,retirement of certain old bills, and weatherization services.The program provides an annual grant which is appliedthrough an even monthly payment plan with the electriccompany. Therefore, EUSP recipients are currentlyrequired to enroll in budget billing.

EUSP - WEATHERIZATION

The EUSP program includes weatherization services for alimited number of EUSP customers. The services areintended to reduce electricity use and electricity bills for ahousehold. The services are available for homeownersand in certain instances, to renters. A person applies forthis with EUSP and MEAP.

APPLIANCE REPAIR AND REPLACEMENT

FURNACES

This program is delivered through DHCD’sWeatherization Assistance Program (WAP) delivery serv-ice network (see page 8). Limited funds are available forhomeowners who meet the MEAP income guidelines.The program helps to replace inoperable boilers and fur-naces or ones that operate at an efficiency level below70%. Eligible renters having problems with their furnacesmay contact the local housing inspection office, if avail-able.

An applicant should contact the local energy office for allOHEP appliance programs. If the person has an emer-gency (i.e., defective or inoperable furnace), he or sheshould inform the agency staff person.

BALTIMORE COUNTY RESOURCE GUIDE

EASTERN FAMILY RESOURCE CENTER9100 FRANKLIN SQUARE DRIVEBALTIMORE, MARYLAND 21237HARRIET HERTZ410-853-3385

See page 6 for a separate list of local centers.

Energy Assistance - O

HEP

Energy Assistance Programs - OHEP

3

If a customer has questions or concerns aboutMEAP/EUSP or the status of an application, thecustomer may call:

DHR CONSTITUENCY SERVICES410-767-71401-800-332-6347

OR

DHR ENERGY ASSISTANCE HOTLINE1-800-352-1446

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BALTIMORE COUNTY RESOURCE GUIDE Docum

ents Needed and Incom

e Guidelines

Documents Needed and Income Guidelines

A person may apply for both MEAP andEUSP (including weatherization) andDHCD's weatherization program (seepage 8) with one application.

MEAPGUIDELINES FOR 2003-2004

These guidelines are used for many energy pro-grams, including MEAP, EUSP, Weatherizationand Fuel Funds. Gross income refers to incomebefore taxes.

DOCUMENTS NEEDED WHEN APPLYING FOR ASSISTANCE

A customer should plan to bring the following informationwhen applying for grants or other assistance:

1. Identification. Driver's license or Maryland ID or employment ID or DSS ID or Green Card.

2. Proof of Residence. Property tax bill or lease or rentbook or current bills mailed to the billpayer’s address.

3. Proof of Income. Examples: Pay stubs (last 4-7weeks), unemployment insurance check stubs, benefitletter (TCA, SSI, SSDI, VA, Social Security), pensionbenefits,disability check, worker's compensation, anyother receipt of income.

4. Social Security Cards. All members of the householdover age 2.

5. Energy Usage. Electric bill, gas and other fuel bills,turn-off notice.

6. Landlord Information. Name, address and telephonenumber.

4

Number of GrossHousehold MonthlyMembers Income

1 $1,1232 $1,5153 $1,9084 $2,3005 $2,6936 $3,085

Each additionalperson add: $393

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EMERGENCY ASSISTANCE TO FAMILIES WITHCHILDREN (EAFC)

EAFC is an emergency grant program that provides fundsfor household emergencies, including utility bills. Theprogram is available to families with one or more childrenunder the age of 21, who are related to and reside with theapplicant, and can only be used once every 12 months. Aperson does not have to be receiving any state assistance toapply for an emergency grant. However, he or she mustdocument individual circumstances.

FLEX FUNDS

Flex Funds are monies provided to all local departments ofsocial services to maintain or reunify children with theirfamilies. These monies are available for a variety ofneeds, but the goods and services purchased must be relat-ed to the child's or family's plan for service. Flex Funds areoften issued for utility bills.

BALTIMORE COUNTY RESOURCE GUIDE Energy Assistance - D

SS and Offices on A

ging

Energy Assistance Programs - DSS

WELFARE AVOIDANCE GRANT (WAG)

These grants may be available to a person who has appliedand is eligible for Temporary Cash Assistance (TCA). Thegrant is intended to address household emergencies orother needs, if circumstances would prevent a householdmember from gaining or continuing employment. A grantusually is awarded in an amount equal to 3 months or lessof assistance benefits. Any person who receives the grantmust forego TCA for the number of months covered by thegrant.

SPECIAL FUNDS OR LOCAL FUNDS

Special Funds, or "Local Funds" are charitable or localfunds administered by local DSS offices. These funds areavailable for household emergencies and are usually allo-cated based upon a household's income and level of need.These funds are not part of any federal or state-mandatedprogram and thus may not always be available.

BALTIMORE COUNTY DEPARTMENT OF AGING611 CENTRAL AVENUE, 2ND FLOORTOWSON, MARYLAND 21204LEE HAGER410-887-2594

You may access the above programs by contactingthe local Department of Social Services in yourarea. Please see the list on the next page.

5

DEPARTMENT OF SOCIAL SERVICES (DSS)

Each local DSS agency has discretion to allocate the funds described below in different ways. All of these funds may beavailable to assist households with children. Flex Funds and Local Funds may be available to single adult households andparticularly older adults (possibly through Adult Protective Services). If a customer currently is not receiving servicesthrough DSS (e.g., TCA, TEMHA), he or she can still contact the local DSS agency for possible assistance with housing andenergy emergencies. Please note that all of these grants are highly discretionary.

This office does provide emergency grants up to a maxi-mum of $250.00. Applicants must (1) be 65 or older;(2) be at risk of being institutionalized; (3) be a Baltimore

County resident; (4) have an income of 60% of the medianincome; and (5) have 50% matching funds so that the grantand the matching funds equal the total balance due.

Offices on Aging

If a customer has questions or concerns about thesefunds or the status of an application, the customermay call:

DHR CONSTITUENCY SERVICES410-767-71401-800-332-6347

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BALTIMORE COUNTY DSS6401 YORK ROADBALTIMORE, MARYLAND 21212BARBARA GRADET410-853-3930

TOWSON OFFICE6401 YORK ROADBALTIMORE, MARYLAND 21212SANDRA PIGOTT410-853-3352

CATONSVILLE OFFICE910 FREDERICK ROADBALTIMORE, MARYLAND 21228MARY JO WOODS410-853-3451

DUNDALK OFFICE7701 DUNMANWAYBALTIMORE, MARYLAND 21222DEBBIE RAMSEUR410-853-3402

ESSEX OFFICE439 EASTERN AVENUEBALTIMORE, MARYLAND 21221CAROL DOMINICK410-853-3810

REISTERSTOWN OFFICE130 CHARTLEY DRIVEREISTERSTOWN, MARYLAND 21136MARGARET OWENS410-853-3009

BALTIMORE COUNTY RESOURCE GUIDE

DEPARTMENT OF SOCIAL SERVICES (DSS) CENTERS

DSS C

ENTER

S

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FUEL FUNDS

Local Fuel Funds offer financial assistance to limitedincome individuals with energy-related emergencies.Fuel Funds generally use EUSP/MEAP income guide-lines for eligibility. Certain Fuel Funds may permit aone-time waiver of the income eligibility requirement,based on individual circumstances. Most Fuel Fundscombine a grant from private funds with (1) a customercontribution, and (2) a matching credit from a utility orits ratepayers. Fuel Funds provide limited grants after acustomer has contacted or obtained help from other pro-grams.

The Baltimore County Fuel Fund serves onlyBaltimore County residents. Grants from this fund aregiven once a year and can be in the form of a cashgrant, BGE credits, or a combined cash and creditaward. The Baltimore County Fuel Fund will award upto a $150 cash grant and $300 in BGE matching credits.Credit awards are used to match one dollar for everytwo dollars paid on an applicant's BGE account.However, BGE credits cannot be used to match federalor state dollars such as an EAFC grant.

The Baltimore County Fuel Fund provides assistancewith BGE utility bill and Emergency Fuel oil. For assis-tance with utility bills eligible applicants must: (1) beincome eligible under MEAP guidelines, (2) have a ter-mination notice, (3) exhaust MEAP, EAFC, and FEMAfunds, (4) have a BGE bill in the applicant's name. FuelFund grants will not be approved unless all monies paidon an applicant's account, (fuel fund grant, applicant'smoney, and private donations, etc.) are sufficient to pre-vent termination or restore service. For assistance withemergency fuel oil, the applicant must: (1) haveexhausted MEAP, EAFC and FEMA funds, if applica-ble, (2) have less than ¼ tank of fuel oil.

For more information, or to apply, call the localCommunity Action Network (CAN) office:

Dundalk 410-285-4674Rosedale 410-887-0433Randallstown 410-887-0631Catonsville 410-747-3312Hillendale 410-339-6457

BALTIMORE COUNTY RESOURCE GUIDE Energy Assistance - O

ther Funds

Energy Assistance - Other Funds

7

FEDERAL EMERGENCY MANAGEMENTAGENCY FUNDS (FEMA)

FEMA is the federal agency responsible for disasterrelief and distributing certain emergency funds to thestate on an annual basis. These funds are available incertain local jurisdictions in Maryland, and may beavailable for a utility emergency.

PRIVATE CHARITIES

FEMA funds are available at the followinglocations:

COMMUNITY ACTION NETWORKDUNDALK410-285-4674

LIBERTY ASSISTANCE CENTERRANDALLSTOWN410-625-9109

CATONSVILLE FOOD MINISTRIES410-747-4357

HEREFORD FOOD BANK410-343-0660

SALVATION ARMY, ESSEX410-753-2920

SALVATION ARMY1400 FUSELAGE AVENUEBALTIMORE, MARYLAND 21220410-682-2450

SOCIETY OF SAINT VINCENT DEPAUL689 RITCHIE HIGHWAYSEVERNA PARK, MARYLAND 21146DONA KENNEDY410-647-4884

SALVATION ARMY511 SOUTH CRANE HIGHWAYGLEN BURNIE, MARYLAND 21061410-768-0477

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DHCD WEATHERIZATION ASSISTANCE PROGRAM (WAP)

WAP is designed to assist limited income families withreducing their energy usage by providing installation ofenergy conserving measures, as well as offering furnacecleaning and tuning. WAP eligibility is based on MEAPguidelines. WAP is funded by the United States Departmentof Energy and is administered through the state by theDepartment of Housing and Community Development(DHCD). DHCD also administers BGE's low-income con-servation program (CHIP). BGE's program includes signifi-cant funding for gas boiler and gas furnace repairs andreplacement.

DHCD SPECIALLOANS PROGRAM

The Special Loans Program administers the MarylandHousing Rehabilitation Program. This program providesfunds to limited income homeowners to improve the basiclivability of a home. The program may provide for structuralrepairs and installation of energy efficiency measures. Thefunds are available for single family owner-occupied proper-ties and rental properties of one to four units.

RENTAL ASSISTANCE PROGRAM (RAP)

This program provides a monthly rental allowance towards aperson's rent for up to 12 months. It is available to homelessindividuals or limited-income households with critical hous-ing needs.

BALTIMORE COUNTY RESOURCE GUIDE

Conservation and Housing Programs

Conservation and H

ousing

COMMUNITY ASSISTANCE NETWORK, INC.7701 DUNMANWAYBALTIMORE, MARYLAND 21222410-285-4674

BALTIMORE COUNTY HOUSING REHABILITATION PROGRAMONE INVESTMENT PLACE, SUITE 800TOWSON, MARYLAND 21204DEBBIE SPARKS410-887-3124

BALTIMORE COUNTY HOUSING OFFICEONE INVESTMENT PLACE, SUITE P-3BALTIMORE, MARYLAND 21204LOIS RUIZ410-887-4000

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EARNED INCOME TAX CREDIT

The Earned Income Tax Credit (EITC) is a special tax creditfor limited income workers. A person may be eligible for atax credit even if he or she does not owe any taxes.However, a tax return must be filed.

CHILD TAX CREDIT

The Child Tax Credit is a special tax credit for limitedincome families. A person may be eligible for this tax creditof at least $600 per child even if he or she does not owe anytaxes. However, a tax return must be filed.

FREE TAX SERVICES

To take advantage of various tax credits, there are free taxservices for elderly, disabled, non-English speaking, and lim-ited income households.

BALTIMORE COUNTY RESOURCE GUIDE Tax Credits

Tax Credits

INTERNAL REVENUE SERVICE1-800-829-1040

STATE OF MARYLAND1-800-638-2937

RENTER'S TAX CREDIT

The Renter's Tax Credit (RTC) is a tax credit offered to lim-ited income renters. Eligible renters include limited incomepersons who are (1) under age 60, or (2) 100% disabled. Allrenters aged 60 and over are eligible. The application anddocuments must be received by September 1 of each year.

HOMEOWNER'S PROPERTY TAX CREDIT

This credit is available to Maryland homeowners whoseproperty taxes exceed a fixed percentage of their incomes.The program is available to qualified homeowners regardlessof age. The application and the documents must bereceived by September 1 of each year.

STATE DEPARTMENT OF ASSESSMENTSAND TAXATION301 WEST PRESTON STREET, ROOM 900BALTIMORE, MARYLAND 212011-800-944-7403www.dat.state.md.us

STATE DEPARTMENT OF ASSESSMENTSAND TAXATION301 WEST PRESTON STREET, ROOM 900BALTIMORE, MARYLAND 212011-800-944-7403www.dat.state.md.us

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AARP TAX-AIDE1-888-227-7669

1st CALL FOR HELP1-800-492-6618

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BALTIMORE COUNTY RESOURCE

Telephone Bill A

ssistance

Telephone Bill Assistance

10

TEL-LIFE

This is a low-cost discount telephone service provided byVerizon. This service is limited to customers who receiveTCA, TEMHA, SSI or PAA benefits.

Verizon charges $0.66 for the first 30 local phone calls ona private phone line. After 30 calls, the customer is billedat $0.08 per call. The $5.00 Federal Subscriber LineCharge also is waived, although special fees for 911 andUniversal Service must be paid. Customers who do nothave phone service with Verizon pay half of the line con-nection charge of $48. Customers who have trouble read-ing, seeing or hearing may be eligible for other discounts.

Customers who owe Verizon $100 or more must makearrangements to pay their bill before Tel-Life will beestablished on their line.

Link Up America

This is a Federal plan that may pay half the cost of gettingnew Tel-Life or other phone service hooked up.

To get an application or to get more information,call

1-800-525-0145

To apply for Tel-Life/Link Up America, fill out theapplication and MAIL it (don’t take it) to:

DEPARTMENT OF HUMAN RESOURCESTEL-LIFE UNIT311 W. SARATOGA STREETBALTIMORE, MD 21201

DHR will determine eligibility. If the customer iseligible, DHR will send the application to Verizon.Once the approval is received, Verizon will contactthe customer to arrange for connection of the serv-ice. The process takes approximately 30 days.

Tel-Life is helpful for a household that makes fewphone calls. See the examples in the chart:

If you make thismany local calls per

month:

30 or less

60 (2 calls per day)

90 (3 calls per day)

120 (4 calls per day)

180 (6 calls per day)

210 (7 calls per day)

You’ll pay this muchfor your phone line

and calls:

$0.66

$3.06

$5.46

$7.86

$12.66

$15.06

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CUSTOMERwith utility bill

EUSP(electric assistance)

ADULT SERVICEScontact for referral for:

Special Funds

ADULT SERVICEScontact for referral for:

Special Funds

DEPARTMENT OF SOCIALSERVICES

contact for referral for:EAFC

Special FundsFlex Funds

WAG

FEMA

PRIVATE CHARITIES

FUEL FUNDThis should be your

last stop to maximizefunds

OFFICES ON AGING

MEAP(heating assistance)

UTILITY COMPANY, AGENCY,ASSISTANCE PROVIDER

If customer needs further assistance and is:

OFFICE OF HOME ENERGYPROGRAMS (OHEP)

UTILITY BILL ASSISTANCE FLOWCHART

SINGLE, no children CHILDREN, in household ELDERLY

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Form SC-1

PHYSICIAN CERTIFICATION OF SERIOUS ILLNESS OR LIFE SUPPORT This is to certify that _______________________________ is a resident of: Street Address: ____________________________________ City, State, Zip: ____________________________________ Telephone Number: ________________________________ Relationship to Customer ___________________________ Account Number: __________________________________ THIS SECTION IS TO BE COMPLETED BY A LICENSED PHYSICIAN ONLY I hereby certify that termination of electric and/or gas service will either (check applicable box or boxes): aggravate an existing serious illness* or prevent the use of life support equipment by the person named above.** (Please print) Physician’s Name ___________________________________________ License No. ___________________________________________ Title ___________________________________________ Address ___________________________________________ ___________________________________________ Office Number _________________________Fax Number__________________ E-Mail Address (optional) _____________________________________ Physician’s signature _______________________________________Date _________ This medical certificate is only valid for a period not to exceed 30 days. * "Serious illness" means an illness certifiable by a licensed physician to be such that termination of service during the period of time covered by the certificate would be especially dangerous to the health of the person certified to be seriously ill. **"Life-support equipment" means any electric or gas energy-using device certified by a licensed physician as being essential to prevent, or to provide relief from, a serious illness or to sustain the life of the customer or an occupant of the premises.