Self-Certified Sensitive Online Form

Customer Name (as it appears on your bill)
Name of Self-Certified Sensitive Resident (if different)
Service Address
  • By completing this form, you are confirming that someone in the household has a condition that can be significantly affected by a disconnection and want to apply the sensitive self-certification status to the household.
  • The Self-Certified Sensitive status is valid for only one (1) year after processing.
  • The benefit to self-certification is that in the event of a disconnection of service for non-payment of your bill, we will attempt to reach you through your preferred method of contact (Email, Text, or Voice Call).
  • If we cannot reach you directly through your preferred method of contact, we will send a technician to your door to attempt to make in-person contact prior to the disconnection. Note: The status does not prevent a disconnection of service from occurring.