⚡ UTILITY SHUTOFF
PREVENTION GUIDE

✍️ Letter 1: Electric/Gas Payment Plan Request

To: [Utility Company Name] | Date: ______________

Re: Account # ___________ – Request for Deferred Payment Agreement

Dear Customer Service,

I am writing to request a reasonable payment plan to prevent disconnection of my [electric/gas] service. I am currently experiencing temporary financial hardship due to [job loss / medical emergency / reduced income].

I propose to pay $______ per month in addition to my current bill until the past-due balance of $______ is cleared. I understand that late fees may be waived under your company’s hardship policy (refer to Tariff Rule 14). Please send a written agreement or call me at [phone] to confirm terms.

Thank you,
_________________________
[Your name, address, phone]

💧 Letter 2: Water Shutoff Prevention (Medical necessity)

To: Water Utility / Municipal billing | Date: ______________

Re: Medical certificate & payment arrangement – Account # _______

To Whom It May Concern,

I am attaching a medical certificate (see template below) confirming that a household member has a serious illness that requires continuous water service. Under 42 U.S.C. § 8624 (LIHEAA) and most state utility codes, disconnection is prohibited when a medical emergency exists.

I request a 60-day deferral and a payment plan of $______ per month. Please contact me to finalize. I am prepared to provide documentation within 48 hours.

Sincerely,
_________________________
[Signature, date]

📄 MEDICAL CERTIFICATE – UTILITY SERVICE PROTECTION

Patient name: ________________________________________

Address (service location): ___________________________

Physician statement: I, Dr. ___________________ (MD/DO), certify that the above-named patient has a serious medical condition (diagnosis: ______________________) that would be aggravated or become life-threatening if electric, gas, or water service is disconnected. Continuous service is medically necessary.

Duration of need: from ______________ to ______________ (or ongoing).

Physician signature: _________________________ Date: ________

License #: ________________ Phone: ________________

Note: This certificate is protected under HIPAA and should be submitted to the utility company with a request for medical protection. 30–90 day protection is typical; renewal may be required.

I, ____________________________, declare under penalty of perjury that:

1. My household income has decreased by at least 25% due to [illness / unemployment / other].
2. I am unable to pay my full utility bill without jeopardizing basic needs (food, medicine).
3. I request a