Form Dss 8118 PDF Details

Amid the complexities of managing household utilities, individuals facing economic hardships often find themselves at a crossroads when they are unable to pay their utility bills, particularly during the colder months. The DSS-8118 form serves as a critical resource in such situations, providing a legal avenue for residents in North Carolina to request the continuation of their electric or natural gas services. This form is grounded in the November 14, 1979, order by the N.C. Utilities Commission, amending Rules R12-10 & R12-11, designed to protect the most vulnerable members of the community including the elderly (65 years of age and older) and disabled individuals from service interruptions. By filling out the DSS-8118 form, applicants certify their inability to settle their utility bills in full or through a six-month payment plan due to financial constraints. Additionally, it declares the household's eligibility for the Low Income Energy Assistance Program (LIEAP), although it does not guarantee assistance. The form underscores the earnest declaration of the applicant regarding their situation and includes severe warnings against providing false information, highlighting potential penalties like fines or imprisonment. Thus, the DSS-8118 form not only represents a beacon of hope for those struggling to keep their homes warm or powered but also a commitment to integrity from the applicants, making it an essential document for affected North Carolina residents and the administering agencies alike.

QuestionAnswer
Form NameForm Dss 8118
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdss 8118 ia certification utilities moratorium form

Form Preview Example

TO:

 

 

 

CERTIFICATION UTILITIES MORATORIUM

 

(Electric or Natural Gas Company)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Address)

 

 

 

 

 

 

 

 

 

 

 

DATE:

 

 

(City)

(State)

(Zip)

 

 

 

 

SUBJECT:

Request for Continuation of Services According to the N.C. Utilities Commission Order of

 

 

November 14, 1979, Amending Rules R12-10 & R12-11.

I request that my electric/gas services be continued through March 31,

 

 

 

I according to Rules R12-10 and R12-1 1.

1. I certify that a member(s) of my household is either elderly (65 years of age and older) or disabled:

Elderly:

Name of Household Member

 

Age

 

 

 

Name of Household Member

 

Age

If disabled person in household, give following information:

Name of Household Member

Age

Description of Disability

Has he been certified as disabled by a governmental agency?

Yes

 

No If yes, list name of agency:

2.I certify that I cannot pay my electric/gas bill in full. Also, I certify that I cannot pay my past and current electric/ gas bill in six monthly payments. After paying my other monthly bills, I do not have the necessary resources.

3.I certify that my household meets the eligibility requirements of the Low Income Energy Assistance Program.

CERTIFICATION

I certify that the above information is true. I declare that to the best of my knowledge I am the only person in my

household who has applied for a continuation of services through March 31, I as provided in the November 14, 1979, order of the N.C. Utilities Commission. I am aware that I can be penalized by fine and/or imprisonment for making false statements. Further, I am aware that while I may be eligible, the completion of this application does not entitle me to any assistance under the Low Income Energy Assistance Program.

Applicant's Name (Print or Type)

(Date)

(Applicant's Signature)

Account Number (if known)

Service Address

I hereby certify that based on the information provided me by the above named applicant, that he is eligible for the requested assistance.

Distribution:

Original to Utility Company 1 Copy to Applicant County File Copy

(Local Administering Agency)

(Certifying Agent)

DSS-8118 (2/93)

(Date)

Economic Independence

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1. The Form Dss 8118 will require certain information to be inserted. Make sure the next fields are completed:

Learn how to fill in Form Dss 8118 part 1

2. Once your current task is complete, take the next step – fill out all of these fields - Name of Household Member, Description of Disability, Has he been certified as disabled, Yes, No If yes list name of agency, Age, I certify that I cannot pay my, I certify that my household meets, CERTIFICATION, I certify that the above, Applicants Name Print or Type, Date, Applicants Signature, and Account Number if known with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

I certify that I cannot pay my, No If yes list name of agency, and Description of Disability in Form Dss 8118

It's easy to make errors when completing your I certify that I cannot pay my, thus make sure that you take a second look before you decide to send it in.

3. The following segment is about I hereby certify that based on the, Distribution Original to Utility, DSS Economic Independence, Local Administering Agency, Certifying Agent, and Date - fill in all these empty form fields.

DSS Economic Independence, Local Administering Agency, and Certifying Agent of Form Dss 8118

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