Rhode Island Code of Regulations › Title 810 - Public Utilities Commission › Chapter 10 - Consumer Protection › Subchapter 00 - N/A › Part 1 - Rules and Regulations Governing the Termination of Residential Electric, Gas and Water Service (810-RICR-10-00-1) › Section 810-RICR-10-00-1.21 - Appendix B: Forms

Current through June 14, 2024
A. Form I
(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
B.
				 Form II
(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
C.
				 Form III
(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
D.
				 Form IV
(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/
E.
				 Form V
(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.