FINANCIAL CERTIFICATION FORM (VALID FOR 90 DAYS)

NOTE: You must complete this Financial Certification Form and a Medical Certification Form to continue receiving telecommunications service.

FINANCIAL SELF-CERTIFICATION (VALID FOR 90 DAYS)

I, [insert printed name] hereby certify that I am the person responsible for the charges for telecommunications service at [insert service address], that a seriously or chronically ill person, [insert name of seriously or chronically ill person], resides there, and that I do not have the financial resources to pay the charges for telecommunications service.

I understand that this certificate does not relieve me of the responsibility to pay my bill, and that I must submit another Financial Certification Form every 90 days.

I understand that if I provide false information, I could be denied medical emergency telecommunications services.

[customer's signature] [date]

[customer's social security number] [customer's telephone number] [service address]

[city] [ state] [zip code]

HISTORY OF 17.11.16 NMAC:

Pre-NMAC History:

None.

History of Repealed Material:

17.11.16 NMAC, Customer Protection (filed 12-14-00) repealed 2-1-06.

NMAC History:

17.11.16 NMAC, Customer Protection (filed 12-14-00) was replaced by 17.11.16 NMAC, Consumer Protection, effective 2-1-06.

[17.11.16.34 NMAC - N, 2-1-06]