New Mexico Administrative Code › Title 17 - PUBLIC UTILITIES AND UTILITY SERVICES › Chapter 5 - UTILITY INTERCONNECTIVITY AND COOPERATIVE AGREEMENTS › Part 410 - RESIDENTIAL CUSTOMER SERVICE BY GAS, ELECTRIC AND RURAL ELECTRIC COOPERATIVE UTILITIES › Section 17.5.410.44 - FINANCIAL CERTIFICATION FORM

Current through Register Vol. 35, No. 13, July 16, 2024
FINANCIAL CERTIFICATION (VALID FOR 90 DAYS
				  ONLY)
PLEASE NOTE: to be complete, ALL fields must be filled in,
				  valid and legible.
BY SIGNING BELOW, I, THE ACCOUNT HOLDER, ACKNOWLEDGE THAT
				  THIS CERTIFICATE DOES NOT RELIEVE ME OF MY RESPONSIBILITY TO PAY MY CURRENT AND
				  PAST BILLS WITH (NAME OF UTILITY).
* For administering authority (human services department
				  (HSD) or tribal authority) certification: primary account holder completes
				  Section I, and HSD or tribal authority completes Section II.
OR
* For self certification: primary account holder completes
				  Section III and attaches a copy of the primary account holder's current
				  medicaid eligibility.
(Even when extended medical certification is authorized,
				  financial recertification is required every 90 days for the account
				  holder.)
SECTION I - AUTHORIZATION TO RELEASE INFORMATION -
				  PRIMARY ACCOUNT HOLDER
I, (printed name of primary account holder)_________,
				  authorize administering authority to release to (name of utility) information
				  from my file as deemed necessary for the purpose of qualifying for the medical
				  certification program.
I certify the information provided is true and correct. I
				  understand that if I provide false information, I can be denied continued
				  medical emergency gas or electric utility service.
(primary account holder's
				  signature)__________________________(utility account
				  number)__________________
(primary account holder's social security number)
				  ________________(primary account holder's telephone number) ___________________
				  (service address, city, state, zip code)
				  ___________________________________________
SECTION II - ADMINISTERING AUTHORITY (HSD OR TRIBAL)
				  USE ONLY
I, (name of agency representative)____________________, an
				  authorized representative of (administering authority)__________________ hereby
				  certify that (primary account holder and social security number)
				  ________________________, the primary account holder named in Section I,
				  currently meets the income guidelines as defined by the administering authority
				  (such as low income home energy assistance program (LIHEAP) (agency
				  representative signature)____________________ (phone number and fax number)
				  ______________________ (date)______________
-OR-
SECTION III - SELF CERTIFICATION - PRIMARY ACCOUNT
				  HOLDER - ATTACH COPY OF CURRENT NEW MEXICO MEDICAID ELIGIBILITY FOR PRIMARY
				  ACCOUNT HOLDER
I, (printed name of primary account holder)________________
				  hereby certify that I am the person responsible for the charges for gas or
				  electric utility service at (service address)_______________________and that a
				  seriously or chronically ill person (as defined by Rule
				  17.5.410.7
				  NMAC) (patient's name)___________________ resides there.
I certify the information provided is true and correct. I
				  understand that if I provide false information, I could be denied continued
				  medical emergency gas or electric utility service.
(primary account holder signature) ______________ (date)
				  _________ (primary account holder's social security number)
				  _____________________ (service address, city, state, zip
				  code)_________________________________
It is in the account holder's best interest to make regular
				  payments toward current and past due balances; the account holder is encouraged
				  to contact (name of utility) to make payment arrangements.
SEE OTHER SIDE FOR MEDICAL CERTIFICATION
Revised December 2012