FEB REPLACED BY NMPRC. Advice Notice No Signature/Title ~~.s;-~ David G. Carpenter Senior Vice President-Chief Financial Officer

Transcripción

1 EL PASO ELECTRIC COMPANY THIRD REVISED FORM NO.9 CANCELLING SECOND REVISED FORM NO.9 ( YOUR RIGHTS AND REPONSIBILITIES (SEE ATTACHMENT) '~1y FEB REPLACED BY NMPRC Final Order Case No UT Advice Notice No. 227 Signature/Title ~~.s;-~ David G. Carpenter Senior Vice President-Chief Financial Officer

2 Your Rights and Responsibilities Regarding Discontinuance of Services Dear EI Paso Electric Residential Customer: This notice is to inform you that your EI Paso Electric (EPE) payment is past due. Your service will be disconnected after the date printed on the enclosed bill if payment is not made by then. Upon request, we can provide outstanding charge information to you including the dates of service during which the outstanding charges were incurred and the date and amount of the last payment. As a service to you, this notice outlines ways that you might be able to avoid disconnection under NMPRC Rule NMAC. Please read to determine if you qualify. As a residential customer of EPE, you are given 20 days from the date a bill is rendered before it becomes delinquent and an additional 15 days before your service may be disconnected for nonpayment. If you are financially unable to pay this bill, contact EPE immediately. You can participate in a payment plan if you can demonstrate that you do not have the financial resources to pay the outstanding amount or if you are low income or are subject to other special circumstances. If you qualify, a deferred payment plan is available. IF YOU HAVE DIFFICULTY PAYING THIS BILL, AND FEEL YOU MAY QUALIFY FOR ASSISTANCE IN PAYING YOUR UTILITY BILL FROM THE LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (L1HEAP), OR ANOTHER ASSISTANCE PROGRAM IN YOUR COMMUNITY, CONTACT THE COMMUNITY ASSISTANCE SECTION OF THE HUMAN SERVICES DEPARTMENT AT , THE TRIBAL OR PUEBLO ENTITY THAT ADMINISTERS A TRIBE'S OR PUEBLOS'S L1HEAP, OR THE CUSTOMER SERVICE REPRESENTATIVE AT THIS UTILITY. LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (L1HEAP) APPLICATION FORMS FOR THE LOW INCOME HOME ENERGY ASSISTANCE PROGRAM ARE AVAILABLE AT THE BILLING OFFICES OF THIS UTILITY, AT THE HUMAN SERVICES DEPARTMENT, AND AT THE TRIBAL OR PUEBLO ENTITY THAT ADMINISTERS A TRIBE'S OR PUEBLOS'S L1HEAP. YOU SHOULD RETURN THE APPLICATION FORMS TO THE HUMAN SERVICES DEPARTMENT OR THE TRIBAL OR PUEBLO ENTITY THAT ADMINISTERS THE PROGRAM AND DETERMINES YOUR ELIGIBILITY TO RECEIVE ASSISTANCE. If you believe that there is an error in your billing, contact EPE immediately for a review. After you pay the undisputed amount of your bill, EPE will postpone disconnection of your service until the dispute is resolved. If you or someone in your household is seriously or chronically ill, EPE will not disconnect your service, if at least two days before the disconnection date, we receive an original of the attached EPE Medical and Financial Certification forms. The medical certification form must be completed by a licensed medical professional. An original of the attached financial certification form, stating that you qualify for financial assistance, must be completed by an agency providing assistance in or for the state of New Mexico. o If your service has been disconnected, we will restore service within twelve hours after you have satisfied the certification requirements above. Your obligation to pay your bill is not relieved if service is continued or reestablished because we received these certifications. Between November 15 through March 15, if you qualify for Low Income Home Energy Assistance Program (L1HEAP), you may be protected from having your services disconnected for non-payment. For more information, please call us at TO RESTORE SERVICE THAT HAS BEEN DISCONNECTED, A RECONNECTION FEE OF $25.00 MAY BE CHARGED PLUS APPLICABLE FEES AND TAXES. IF REQUESTED, AN AFTER HOURS PREMIUM OVERTIME RECONNECTION FEE OF $133.00, PLUS APPLICABLE FEES AND TAXES, WILL APPLY. We can put you in touch with other organizations in your community that might be able to help you. If you have a relative, friend, or agency that will assist in paying your bills, and you want EPE to notify them when disconnect notices are sent, contact EPE at EPE's Budget Payment Plan can help even out your payments throughout the year. You still pay for all of the energy you use. You can cancel your participation at any time. Upon cancellation, all amounts are due and become payable within 30 days. Any credits will be applied to your account. Special consideration will be given to a residential customer who meets the qualifications of L1HEAP, or has other special circumstances, in determining deposits and installment agreements. In making a determination, EPE will accept documentation from the administering authority that the residential customer meets the L1HEAP qualifications. See your bill for your local EPE payment office location, or contact us for third-party and other pay locations nearest you. To contact us, call us at from 8:00 a.m. and 4:30 p.m., Monday through Friday (Holiday hours vary), or go to If you are not satisfied with the arrangements that EPE provides, you have the right to file a complaint with the NMPRC, 1120 Paseo de Peralta, Santa Fe, NM Telephone or ASKPRC or Members of New Mexico tribes or pueblos who need help with translation or other matters may contact the Commission's consumer relations division at , who will contact the appropriate tribal or pueblo official for assistance.

3 EL PASO ELECTRIC COMPANY THIRD REVISED FORM NO.9 CANCELLING SECOND REVISED FORM NO.9 x X FINANCIAL CERTIFICATION Page 2 of 6 (SEE ATTACHMENT) c~v FEB HEPLfiCEf) BY NMPFi(; Final Order Case No UT Advice Notice No. 227 SignaturelTitle ~~~~ David G. Carpenter ' Senior Vice President-Chief Financial Officer

4 n.. c... :.c PIlUIC; IV ue I..VIIIIJIt:lt:, ALL IlelUS muse De Tlilea In, VaIlQ, ana leglole. FINANCIAL CERTIFICATION (VALID FORgO DAYS ONLy) BY SIGNING BELOW, I, THE ACCOUNT HOLDER, ACKNOWLEDGE THAT THIS CERTIFICATE DOES NOT RELIEVE ME OF MY RESPONSIBILITY TO PAY MY CURRENT AND PAST BILLS WITH (NAME OF UTILITY). For Administering Authority (Human Services Department (HSD) or Tribal Authority) certification: complete Sections I and II. OR For self certification: complete Section III and attach a copy of the primary account holder's current Medicaid eligibility. (Even when Extended Medical Certification is authorized I Financial Recertification is required every 90 days for the Account Holder.) SECTION I : AUTHORIZATION TO RELEASE INFORMATION - PRIMARY UTILITY ACCOUNT HOLDER I, I authorize Administering Authority to release to (name of utility) information from PRINTED NAME OF PRIMARY ACCOUNT HOLDER my file as deemed necessary for the purpose of qualifying for the Medical Certification program. I certify the information provided is true and correct. I understand that if I provide false information, I can be denied continued medical emergency gas or electric utility service. PRIMARY ACCOUNT HOLDER'S SIGNATURE PRIMARY ACCOUNT HOLDER'S TELEPHONE NUMBER UTILITY ACCOUNT NUMBER SERVICE ADDRESS PRIMARY ACCOUNT HOLDER'S SOCIAL SECURITY NUMBER CITY STATE ZIP CODE SECTION II - ADMINISTERING AUTHORITY (HSD OR TRIBAL) USE ONLY I --';"'-nc"""""fv","""'=io'ic","vc~' an authorized representative of ---.;""...""...'"'''"itil''''''''~----- hereby certify that NAME OF AGNECY REPRESENTATIVE ADMINISTERING AUTHORITY --';,""=iiv"''''''''''''''''''''''-'-''''''''',,,",,"''''idftv,,",'''''''-~' the primary account holder named In Section I currently meets the income PRIMARY ACCOUNT HOLDER AND SOCIAL SECURITY NUMBER guidelines as defined by the Administering Authority (such as Low Income Home Energy Assistance Program (UHEAP) assistance). AGENCY REPRESENTATIVE SIGNATURE CONTACT NUMBER AND FAX NUMBER -OR- SECTION III -SELF CERTIFICATION - PRIMARY ACCOUNT HOLDER - ATTACH COpy OF CURRENT NEW MEXICO MEDICAID ELIGIBILITY FOR PRIMARY ACCOUNT HOLDER I, hereby certify that I am the person responsible for the charges for gas or electric PRINTED NAME OF PRIMARY ACCOUNT HOLDER utility service at ===~c-cc==c-- and that a seriously or chronically ill person (as defined by Rule SERVICE ADDRESS DATE NMAC) ---====0-=-:-;-0;:: resides there. PATIENT'S NAME I certify the information provided is true and correct. I understand that if I provide false information, I could be denied continued medical emergency gas or electric utility service. PRIMARY ACCOUNT HOLDER SIGNATURE DATE PRIMARY ACCOUNT HOLDER'S SOCIAL SECURITY NO. SERVICE ADDRESS CITY STATE ZIP CODE It is in the account holder's best interest to make regular payments toward current and past due balances; the account holder is encouraged to contact (name of utility) to make payment arrangements. SEE OTHER SIDE FOR MEDICAL CERTIFICATION Revised December, 2012

5 EL PASO ELECTRIC COMPANY THIRD REVISED FORM NO.9 CANCELLING SECOND REVISED FORM NO.9 x X MEDICAL CERTIFICATION Page 30f6 (SEE ATTACHMENT) FEB REPLACED BY NMPRC Final Order Case No UT Advice Notice No. 227 Signature/Title ~\b,.~ David G. Carpenter Senior Vice President-Chief Financial Officer

6 PLEASE NOTE: To be complete, ALL fields must be filled In, valid, and legible, MEDICAL CERTIFICATION NOTE: In order to continue to receive gas or electric service from (name of utility), a complete Medical and a complete Financial Certification Form must be submitted. This certification Is vajld for ninety (90) days from the signature date of medical professional. PATIENT OR LEGAL GUARDIAN I certify the information provided is true and correct, I understand that if I provide false information, I could be denied continued medical emergency gas or electric utility service from ' Name of Utility Company I, 1 hereby authorize the medical professional signing this certification to PRINTED NAME OF PATIENT disclose to the Information contained In this Medical Certification Form, Name Of Utility Company PATIENT OR LEGAL GUARDIAN SIGNATURE DATE PRIMARY UTILITY ACCOUNT HOLDER I certify the information provided is true and correct. I understand that if I provide false information, I could be denied continued medical emergency gas or electric utility service from, Name of Utility Company I,, hereby certify that I am the person responsible for the charges for gas PRINTED NAME OF PRIMARY ACCOUNT HOLDER or electric utility service at -===-===::- and that a seriously or chronically III person SERVICE ADDRESS (as defined by Rule 17.5,410,7 NMAC) resides there. I further certify that I will Immediately notify or arrange to have such notification provided, if Name Of Utility Company there Is a change in the status of the seriously or chronically III person residing at the Service Address, Including relocation or a change In the physical condition of such person which renders continued medical emergency gas or electric utility service unnecessary, PRIMARY ACCOUNT HOLDER SIGNATURE DATE DOCTOR'S USE ONLY I, 1 certify that: I am (1) a licensed physician or physician's assistant licensed or PRINTED NAME OF MEDICAL PROFESSIONAL accepted by the New Mexico Medical Board and practicing under the New Mexico Medical Practice Act, (2) an osteopathic physician or osteopathic physician's assistant practicing under the New Mexico Osteopathic Physician's Practice Act or (3) a certified nurse practitioner licensed by the New Mexico Board of Nursing and practicing under the New Mexico Nursing Practice Acti I hold license number/npi Number and that on DATE I examined who I am Informed resides at NAME OF PATIENT SERVICE ADDRESS I certify that the said person has the following condition in which loss of gas or electric (please indicate type of service by checking) utility service would give rise to substantial risk of death or gravely impair health: DESCRIBE CONDITION AND REASONS FOR CONTINUED GAS OR 'ELECTRIC UTILITY SERVICE (IF APPLICABLE, LIST MEDICALLY NECESSARY EQUIPMENT) and that this condition qualifies as a serious or chronic illness pursuant to Rule NMAC. DEFINITION OF SERIOUS OR CHRONICALLY ILL PER RULE NMAC' AN ILLNESS OR INJURY THAT RESULTS IN A MEDICAL PROFESSIONAL'S DETERMINATION THAT THE LOSS OF GAS OR ELECTRIC UTILITY SERVICE WOULD GIVE RISE TO A SUBSTANTIAL RISK OF DEATH OR GRAVELY IMPAIR HEALTH. SIGNATURE OF MEDICAL PROFESSIONAL DATE OFFICE ADDRESS OF MEDICAL PROFESSIONAL TELEPHONE NUMBER, AND FAX NUMBER OF MEDICAL PROFESSIONAL ONLY for patients meeting the requirements for extended medical certification, also complete the additional certification below if it applies to this patient: DOCTOR'S USE ONLY EXTENDED MEDICAL CERTIFICATION VALID FOR 1 YEAR ---=-==~::-:-::-:c::c=::-::_:c_==::::==------_certlfy that the above mentioned patient's medical condition PRINTEO NAME OF MEDICAL PROFESSIONAL -:c=====-:-::===-==:o:::::;--,is permanent and will not Improve within 12 months from (today's date,) DESCRIPTION OF APPROVED CONDITION SEE OTHER SIDE FOR FINANCIAL CERTIFICATION RevIsed December, 2012

7 EL PASO ELECTRIC COMPANY THIRD REVISED FORM NO.9 CANCELLING SECOND REVISED FORM NO.9 x X YOUR RIGHTS AND REPONSIBILITIES Page 4 of 6 (SEE ATTACHMENT) --v FEB ({[PlACED BY NMPRC Final Order Case No UT Advice Notice No. 227 Signature/Title ~~~ David G. Carpenter Senior Vice President-Chief Financial Officer

8 Sus Derechos y Responsabilidades Respecto a la Desconexi6n de Servicios Estimado Cliente Residencial de EI Paso Electric: La presente aviso es para informarle que el pago de su cuenta con EI Paso Electric (EPE) ha vencido. Su servicio sera desconectado despues de la fecha impresa en la factura adjunta sl el pago no se ha realizado para entonces. De ser solicitado, pod em as proveerle informacion sobre los cargos pendientes de pago incluyendo las fechas de servicio durante las cuales se incurrio en los cargos pendientes de pago y la fecha y cantidad del ultimo pago. Como un servicio para usted, el presente aviso describe las maneras en que puede evitar la desconexi6n en virtud de 10 establecido en la Regulacion NMPRC NMAC. Par favor leal a para determinar si usted califica. Como cliente residencial de EPE, se Ie otorgan 20 dias a partir de la fecha en que se Ie entrega la factura para efectuar el pago antes de que venza, y 15 dias adicionales antes de desconectarle el servicio par falta de pago. Si par su situacion econ6mica Ie es imposible realizar el pago de esta factura, comunfquese con EPE de inmediato. SI TIENE DIFICULTAD PARA PAGAR ESTE FACTURA, Y SIENTE QUE PUEDE CALIFICAR PARA ASISTENCIA EN EL PAGO DE LOS FORMULARIOS DE SOLICITUD DEL PROGRAMA DE ASISTENCIA PARA EL PAGO DE ENERGfA EN HOGARES DE BAJOS INGRESOS (LiHEAP) PARA PARTICIPAR EN DICHO PROGRAMA ESTAN DISPONIBLES EN LAS OFICINAS DE COBRO DE ESTA Si cree que existe un error en su factura, comunfquese con EPE de inmediato para una revisi6n. Una vez que pague la cantidad no sujeta a disputa de su factura. EPE pospondra la desconexion de su servicio hasta que la disputa sea resuelta. Si usted 0 alguien de su hogar padece de una enfermedad grave a cronica, EPE no desconectara su servicio si por 10 menos dos dlas antes de la fecha de desconexi6n recibimos un original de los formularios adjuntos consistentes en Certificaci6n Medica y Certificaci6n Financiera de EPE. EI formulario de certificacion medica debe ser completado por un profesional medico licenciado. Una agencia que provea asistencia n 0 para 81 estado de Nuevo Mexico debera completar en original en formulario de certificacion financiera adjunta can la declaracion de que usted califica para asistencia financiera. Del 15 de noviembre al 15 de marzos, si usted califica para el Programa de Asistencia para el Pago de Energla de Hogares de Bajos Ingresos (LiHEAP), podra estar protegido contra la desconexion de sus servicios por falta de pago. Para mas informacion, par favor Iiamenos EPE al PARA RESTAURAR EL SERVICIO QUE HA SIDO DESCONECTADO SE PODRfA COBRAR UNA CUOTA DE RECONEXfoN DE $25.00 MAs CARGOS E IMPUESTOS APLICABLES. SI ES SOLICITADO PARA HORAS INHABILES APLICARA UNA CUOTA DE RECONEXl6N PRIMIUM PARA HORARIOS EXTRAORDINARIOS DE $133.00, MAs CARGOS E IMPUESTOS APLICABLES. Podemos porterlo en contacto con otras organizaciones en su comunidad que es probable que puedan ayudarlo. Si cuenta can un familiar, amigo 0 agencia que asista en el pago de sus facturas, y usted desea que EPE les notifique cuando se envian avisos de desconexi6n, comunlquese con EPE ai EI Plan de Pago Presupuestado de EPE puede ayudarlo a nivelar sus pagos a traves del ano. Usted sigue pagando por la electricidad que usa. Su participacion puede ser cancelada en cualquier momento. AI cancelar el plan, todas las cantidades vencen y se hacen pagaderas a los 30 dlas. Los creditos que existan seran aplicados a su cuenta. Se Ie prestara consideracion especial a un cliente residencial que reuna las calificaciones del programa LlHEAP, 0 que tenga otras Vea su factura para ubicar la oficia de pagos de EPE de su localidad. 0 comuniquese con nosotros para ubicaciones de otros lugares de Usted pod ria participar en un plan de pagos si demuestra que no tiene los recursos financieros para pagar la cantidad pendiente de pago a si es de bajos ingresos 0 esta sujeto a otras circunstancias especiales. SI califica, hay disponibles convenios de pagos a planes diferido de financiamiento. SU CUENTE DE SERVICIOS MEDIANTE EL PROGRAMA DE ASISTENCIA PARA EL PAGO DE ENERGfA EN HOGARES DE BAJOS INGRESOS (LiHEAP ~OR SUS SIGLAS EN INGLES), U OTRO PROGRAMA DE ASISTENCIA EN SU COMUNIDAD, COMUNIQUESE CON LA SECCION DE ASSISTENCIA COMUNITARIA DEL DEPARTMENTO DE SERVICIOS HUMANOS LLAMADO AL , CON LA ENTIDAD TRIBAL 0 PUEBLO QUE ADMINISTfl,A EL PROGRAM A LlHEAP DE LA TRIBU 0 PUEBLO, o CON EL REPRESENTANTE DE SERVICIO AL CLiENTE DE ESTA COMPANIA DE SERVICIOS. COMPANIA DE SERVICIOS, EN EL DEPARTAMENTO DE SERVICIOS HUMANOS Y EN LA ENTIDAD TRIBAL 0 PUEBLO QUE ADMINISTRA EL PROGRAMA LIHEAP DE LA TRIBU 0 PUEBLO. LOS FORMULARIOS DE SOLICITUD DEBEN SER ENTREGADOS AL DEPARTAMENTO DE SERVICIOS HUMANOS 0 ENTIDAD DE TRIBU 0 PUEBLO QUE ADMINISTRA EL PROGRAMA Y DETERMINA SU ELiGIBILIDAD PARA RECIBIR ASISTENCIA. o Si su servicio ha side desconectado, Ie restableceremos el servicio en las dace horas siguientes a que usted haya satisfecho los requerimientos de certificacion anteriores. La obligaci6n del pago de su factura no es eximida si se Ie continua prestando el servicio o si el servicio es restablecido debido a que recibimos dichos certificados. circunstancias especiales, en determinar depositos y convenios de pagos a plazos. AI hacer una determinacion, EPE aceptara documentacion de la autoridad administradora que indique que el cliente residencial reune las calificaciones para programa LlHEAP. pago 0 de terceros mas cercanos a usted. Para comunicarse can nosotros, Iiamenos al en horario de 8:00 a.m. a 4:30p.m., de lunes a viernes. Los horarios de feriados varian, 0 ingrese a Si no esta satisfecho con los arreglos que Ie provea EPE, usted tiene el derecho de presentar un reclamo ante la NMPRC, 1120 Paseo de Peralta, Santa Fe, NM 87501, telslono (505) a Los miembros de las tribus 0 pueblos de Nuevo Mexico que necesitan ayuda para la traduccion u otros asuntos pueden ponerse en contacto con la division de relaciones con el consumidor de la Comision Ilamado ai , quienes se comunicarim con el oficial de la tribu 0 pueblo apropiado.

9 EL PASO ELECTRIC COMPANY THIRD REVISED FORM NO.9 CANCELLING SECOND REVISED FORM NO.9 x X FINANCIAL CERTIFICATION Page 5 of 6 (SEE ATTACHMENT) V FEB HEPLIICED BY filmprc Final Order Case No. U:Q938S-UT Advice Notice No. 227 Signature/Title ~,~ David G. Carpenter ' Senior Vice President-Chief Financial Officer

10 CERTIFICACION FINANCIERA (VALIDA POR 90 DIAS) ATENCION: para collsideral' la fol'illa completa Ilene TOnOS espacios ell blanco, sel' vj\lidos y legibjes AL FIRMAR A CONTINUACION, YO EL TITULAR DE LA CUENTA, RECONOZCO QUE ESTE CERTIFICADO NO ME LIBERA DE MI RESPONSAEILIDAD FINANCIERA DE PAGAR MIS FACTURAS ACTUALES Y ANTERIORES CON EL PASO ELECTRIC COMPANY. Autoridad Administradora (Departamento de Recursos Humanos 0 Autoridad Tribal) Certificado: complete Secci6n I y II. D Para la auto certificaci6n: complete Seeci6n III y adjullte una eapia de Elegibilidad de Asistencia Medica (Medicaid) del actual titular de la cuenta principal (Inc/usa cuando la certificaci6n medica proiongada sea autori=ada, se requiel'e l'e~cel'/ificaci6nfil?anciera cada 90 dfas pol' parte del titular de la cuenla) YO,, doy autorizaci6n a la Autoridad Administradora de proporeionar (nombre del proveedor) clialquier NOMBRE IMPRESO DEL TITULAR PRINCIPAL informaci6n que se considere necesaria con el prop6sito de califiear para el Programa de Certifieaci6n Medica. Yo certifico que la illformaci6n proporcionada es correcta y vel'dadera. Entiendo que si doy infol'maci6n falsa se me puede!legal' el servicio de emergencia medico prolongado pol' parte de la compafua de servicio de gas 0 electricidad. FIRMA DEL TITULAR PRINCIPAL NUMERO DE CUENTA SEGURO SOCIAL DEL TITULAR PRINCIPAL NUMERO DE TELEFONO DEL TlTULA PRINCIPAL DIRECCION DEL SERVICIO CIUDAD ESTADO CODIGO POSTAL YO,, representante autorizado de _-,--- --,-- NOMBRE DEL REPRESENTANTE AUTORIDAD ADMINISTRATIVA certifieo que es el titular principal de la cuenta en Secci6n I Actualmcllte cum pie con los NOMBRE DEL TITULAR PRINCIPAL Y NUMERO DE SEGURO SOCIAL reguisitos de bajos ingrcsos como es definido por la Autoridad Administradora para el Programa de Asistencia El1ergetica para Personas de Baja:> Recursos (LlHEAP por sus siglas en ingles). FIRMA DEL REPRESENTANTE NUMERO DE TELEFOND & FAX FECHA -0- SE(X;IOI'IiIL~ AUTO CERTIFIC.;I,CIONo,: TITuI.;Aifi'RiNClPAl/bJc.LA cuil;n;c:a-':cadju,ntjc COI'IAnEL CER'IIFICADO DE-ELEGIBILIDAD DE ASISTENCIA_MEIlICA ~1tbXCAID) DEL TlT\!LAR p,rincn' AL YO,===-="""=====o-c====o----, celtifico que soy la persona responsable de los cargos por los servieios de gas 0 electricidad en NOMBRE II\1PRESO DEL TITULAR PRINCIPAL _-;:=====--;;;=== y que una persona gravemente 0 cr6nicamente enferrna (de acuerdo a 10 definido en la Regia de NMAC DlRECCION DEL SERVICIO _--;c.====-;;cc;;-;== reside aqul NOMBRE DEL PACIENTE Yo certifico que la informaci6n proporcionada es correcta y verdadel'a. Entiendo que si doy informaci61l falsa se me puede uegar el servicio de emej'gencin medico pj'oiongado pol' parte de Ia companfa de servicio de gas 0 electricidad. FIRMA DEL TITULAR PRINCIPAL NUMERO DE CUENTA SEGURO SOCIAL DEL TITULAR PRINCIPAL NUMERO DE TELEFONO DEL TlTULA PRINCIPAL DIRECCION DEL SERVICIO CIUDAD ESTADO CODIGO POSTAL Es en el mejor interes en el Titular de la Cucnta hacer pagos hacia saldos adeudados actuales y antcriores, Ie suplicamos se comunique (nombrc del provecdor) para hacer arreglos de pago. Revision de Dlclembre 2012 VER EL REVERSO PARA LA CERTIFICACION MEDICA

11 EL PASO ELECTRIC COMPANY THIRD REVISED FORM NO.9 CANCELLING SECOND REVISED FORM NO.9 x X MEDICAL CERTIFICATION Page 6 of 6 (SEE ATTACHMENT) FEB '1 2m3 REPLACED fly NMPRC Advice Notice No. 227 Signature/Title S: :.\~)~ David G. Carpenter Senior Vice President-Chief Financial Officer Final Order Case No UT

12 CERTIFICACION MEDICA ATENCION: para considcrar la forma completa Ilene TODOS espacios en blanco, ser vli.lidos y legibles ANTENcrON: Con el fin de continuar recibiendo servicio de gas 0 electricidad un examen Medico completo y L1na Certificaci611 Financiera completa debe ser proporcionada. Esta celtificaci6n es valida por (90) dias a partir de la firma del medico. PACIENTEOTUTORLEGAL Yo certifico que la informaci611 proporcionada cs correcta y verdadera. Entiendo que si doy illformaci6n falsa se me puede negar el servieio de emergencia medico proiongado por parte de ~===""'c;c"'==="'=======-;-;o=:-~~ NOMBRE DE LA COMPANIA DESERVICIOS PUBLICOS YO, pol' media de la presente autorizo al personal medico que firma esta certificaci6n revelar informaci6n a NOMBRE IMPRESO DEL PACIENTE ;WU;=;;-;;;;-;7-;V;;C;;;-'-"","",,;;--';;;;;"";;;;O;;;-n,;;;;-;;:;o;;;-~~- NOMBRE DE LA COMPANIA DE SERVICIOS PUBLICOS contenida en este formulario Medico. FIRMA DEL PACIENTE 0 TUTOR LEGAL FECHA TJTULARPRINCifALDELA CUENTA Yo certified que la informaci6n proporcionada es correcta y verdadera. Entiendo que si doy informaci6n falsa se me puede negar el servicio de emergencia medico prolongado por parte de ~=="";-;o;;;-;-:;c""=;-;;;;;-,~;o;;;;;c""===;;-;=-;;-~~ NOMBRE DE LA COMPANIA DE SERVICIOS PUBLICOS YO,. certifieo que soy 1a persona responsable de los cargos por el servicio de gas 0 electricidad en NOMBRE IMPRESO DEL TITULAR PRINCIPAL ~~~~~~~~~~~===="",~co:;;;;;-;;;o;;;;-~~~~~-y que una persona gravemente 0 cr6nicamellte enferma (de acuerdo a 10 definido en DlRECCION DEL SERVICIO JaRegla de NMAC reside aqu!. Ademas certified que notificare inmediatamcnte a ~=====-;-=============:;;-~_ 0 hare arreglos para que dicha notificaci6n sea NOMBRE DE LA COMPANIA DE SERVICIOS PUBLICOS proporcionada, en caso de que existan cambios en el estatus de 1a persona gravemente 0 cr6nicamente enfenna can domicilio en la direcci6n de servicio incjuyendo la reubicaci6n 0 condici6n flsica de la persona que provee servicio de emergencia medico prolongado par parte de la campania de servicio de gas 0 electricidad si estos servicios Jlegaran a ser no necesarios. FIRMA DEL TITULAR PRINCIPAL FECHA YO, ' certifico que: (1) soy un medico can licencia 0 asistente de medico con Iicencia aprobado par el Consejo NOMDRE IMPRESO DEL MEDICO Medico de Nuevo Mexico y ejerciendo bajo 1a Ley Medica de Practicantes de Nuevo Mexico, (2) medico de osteopatia a asistente de medico de osteopatfa, ejerciendo bajo 1a Ley de Osteopatla de Nuevo Mexico, 0 (3) enfemlera certificada por el Consejo de Enfemleria de Nuevo Mexico y ejerciendo bajo la Ley de Enfermeria de Nuevo Mexico; mi numero de licencialnumero NPI es ; y que en ~--o==;-~~--~~~- FECHA Exarninea. ~~~~~~~~==;-~~~~~~~_ y que se me ha infonnado que reside en.m;c;;;;;;;;;;:;ru"o;;m;;;c;;~~~~~~~ NOMBRE DEL PACIENTE DIRECCION DEL SERVICIO Yo certifico que dicha persona padece de la siguiente condici6n y que la perdida del servicio de ~_ gas 0 ~_ electricidad (favor de indicar) causaria un dafio irreparable tal como 1a muerte 0 un grave deterioro de la salud: DESCRIBA LA CONDICION Y RAZONES PARA CONTINUAR CON EL SERVICIO DE GAS 0 ELECTRICIDAD (SI APLICA, LISTE EL EQUIPO MEDICO NECESARIO) Y que esta condici6n medica es establecida como L1na enfermedad grave 0 cr6nica de acuerdo a Ja Regia NMAC. ~f.lf1ffi!f,.f;~~ffiih ~~~~~'t,~fif1~xl~~~~:t.~fl!~~~> 1~~~'cyU6NA ENFERMEDAD 0 LESION QUE RESULTE EN LA D IRREPARABLE TAL COMO LA MUERTE 0 UN GRAVE DETERIORO DE LA SALVO. DE GAS 0 ELECTRICIDAD CAUSARIA UN DANO FIRMA DEL MEDICO FECHA DOMICILIO DEL CONSULTORIO MEDICO NUMERO DE TELEFONO Y FAX SOLAMENTE para pacientes que cum pie con los requisitos de certificaci6n medico projongado, debenin lienar el celtificado adicional a continuaci6n, solamente si aplica a este paciente. usa MEIiiCO-SQLAMENTE'" CERTIFICACI01'I MEDlCAPROLONGADA (VALIIJA POR UN ANO) Yo certifico que la condici6n medica del paciente antes mencionado =======-7C====.C=~~~~- NOMBRE IMPRESO DEL MEDICO DESCRIPCION DE LA ENFERMEDAD Es una enfermedad perinanente y que no tendril mej~ria en los pr6ximos doce meses a partir de (feeha actual). Revision de Dlciembre 2012 VER EL REVERSO PARA LA CERTIFICACION FINANClERA