Planes de pago y asistencia

Financial Statement Form

If you meet certain income requirements, you may be eligible for special payment agreement terms.

Thank You for Submitting Your Eligibility Form

We are reviewing your information and will contact you as soon as possible. Please allow us approximately 30 days to complete our review. Filling out the form does not guarantee eligibility. If you have any questions, please contact us.

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Having trouble paying your bills? We’ll try to help. Please provide your financial information and we’ll let you know if you’re eligible for special payment agreement terms.

Contact Information

ALL FIELDS ARE REQUIRED, UNLESS OTHERWISE NOTED

Name

Email Address

Daytime Phone Number

Account Number (15 Digits)

Household Occupants

Income and Government Benefits

Please enter your gross monthly household income and monthly benefits received from any government programs.

Gross Monthly Household Income (If Applicable)

Public Assistance Monthly Benefit (If Applicable)

Social Security Monthly Income (If Applicable)

Supplemental Security Income (SSI) Monthly Benefit (If Applicable)

Monthly Unemployment Insurance Income (If Applicable)

Monthly Food Stamp Benefit (If Applicable)

Other Income (If Applicable)

Total Monthly Income and Benefits

Expenses

Please enter your approximate monthly expenses.

Rent/Mortgage (If Applicable)

Groceries (If Applicable)

Medical/Dental (If Applicable)

Other Expenses (If Applicable)

Total Monthly Expenses

Please let us know if you have any additional comments or special circumstances you would like to share (Optional)

Please provide details

Please allow us approximately 30 days from the date of your submission to complete our review and respond to your request.

Your electronic signature is the same as your handwritten signature and is certification of the truth and accuracy of the information submitted. Your signature confirms that all of the information provided on this form is true and accurate to the best of your knowledge.

Signature

Date

Error: This field is required.

Please choose the option that best describes you.

Residential Customer

Commercial Customer

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