16 CRR-NY App. 17NY-CRR

OFFICIAL COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK
TITLE 16. DEPARTMENT OF PUBLIC SERVICE
16 CRR-NY App. 17
16 CRR-NY App. 17
A MODEL LETTER AND FORM FOR DOCUMENTATION OF INABILITY TO PAY UTILITY BILLS UNDER 16 NYCRR 633.5
We have received an initial certificate of medical emergency, under which we must continue to provide you utility service for 30 days, starting __ and continuing until the beginning of business on __.
At the expiration of that period, we can, under the provisions of the Public Service Commission's regulations (633.5), terminate your utility service UNLESS the medical condition persists AND you do not have enough ready cash or income to meet your past-due and current utility bills and still meet your other necessary expenses such as food, housing, heating and medical treatment.
We enclose a form that you can use to provide the information we need to make a determination, as required by regulation, whether you are unable to pay past-due and current bills. We will continue to provide you utility service while we consider the information you provide.
If we determine that you have NOT demonstrated that you are unable to pay past-due and current bills, we will notify you in writing and inform you how you can seek review of our determination by the Public Service Commission.
If we determine that you have NOT shown that you have a financial hardship, we will offer you a deferred payment agreement, so that you can pay past-due bills and installments while you meet all current bills. And if you DO show a financial hardship, we will try to work out an arrangement so that you will not accumulate substantial past-due bills.
If you have any questions, you can call (local utility office/customer representative) at XXX-XXXX. If you are not satisfied with our response, you also can call the Public Service Commission between the hours of 9:00 a.m. and 4:45 p.m., Monday through Friday, at 1-800-342.3377.
Very truly yours,
(A) INFORMATION ON LIQUID ASSETS AND CURRENT INCOME.
(A) (1) Liquid assets, such as cash, bank savings or checking accounts, etc. should be listed.
Cash on hand $ ___
Bank checking account No.
__
 
Amt. presently in account $ __
Bank savings account No.
__
 
Amt. presently in account $ __
Name and address of banks
 
(A) (2) Income information:
 
(week)
Source of Income:
 
Work Yes
__
No
__
Amt.
__
(month)
 
SSI Yes
__
No
__
Amt
__
per mo.
Public or other
 
Yes__ No__ Amt. __ per 2 wks Assistance
(A) (3) EXPENSES
 
MONTHLY PAYMENT
 
AMT. OWING
 
Housing: Rent_ Own_
Food: Food Stamps: Yes_ No_
Medical expenses:
 
(incl. prescriptions)
Utility: (gas and electric)
Heating: (if not gas or electric)
Telephone:
Installment payments: (credit card)
Transportation:
Car expense: (loan, gas, etc.)
Education:
Other:
 
I, the undersigned, do hereby certify that the above information provided is the truth, to the best of my knowledge.
(signature)
(date)
16 CRR-NY App. 17
Current through March 15, 2020
End of Document© 2020 Thomson Reuters. No claim to original U.S. Government Works.