New Mexico Administrative Code
Title 17 - PUBLIC UTILITIES AND UTILITY SERVICES
Chapter 11 - TELECOMMUNICATIONS
Part 25 - CONSUMER PROTECTION STANDARDS APPLICABLE TO LARGE INCUMBENT LOCAL EXCHANGE CARRIERS
Section 17.11.25.25 - FINANCIAL CERTIFICATION FORM

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]