Service Disconnect Notice

SERVICE DISCONNECT NOTICE

Provider Name:    Provider Contact Phone:

Client Name:    Service Address:

Account Number:    Service Type:

RECITALS

WHEREAS, Provider furnishes the service identified above to Client under the terms and conditions of a governing service agreement or tariff and maintains responsibility for billing and collection of charges for that service; and

WHEREAS, Client has failed to satisfy amounts owing or otherwise violated a material term of the service agreement as specified below; and

WHEREAS, Provider issues this written notice informing Client of the action to be taken, the amounts required to avoid service disconnection, and the conditions for reconnection.

NOTICE INFORMATION

Notice Date:

Proposed Disconnect Date:    Earliest Disconnect Time:

REASON FOR DISCONNECT

Nonpayment of charges    Violation of service terms    Safety or unauthorized use

Description of Basis for Disconnect:

SCOPE OF WORK

The Provider will effectuate a physical or electronic discontinuation of service at the Service Address identified above if Client fails to cure as set forth in this notice. The scope includes notification delivery, disconnection of service apparatus or termination of account access, and any necessary site visits to secure the service point. Reconnection shall occur only upon fulfillment of all conditions in Payment Terms and Reconnection Conditions below.

PAYMENT TERMS

Amount Due to Avoid Disconnect: $    Billing Period:

Payment Schedule and Options:

Late Fee:    Reconnection Fee: $

TERM AND TERMINATION

Effective Start Date:

Termination Event: Service shall be disconnected on the Proposed Disconnect Date unless Client cures the breach by paying the Amount Due or otherwise complying with the terms set forth in this notice. Provider may terminate or suspend service earlier if immediate hazard or fraud is discovered.

Notice Period to Cure: days from the Notice Date shown above.

RIGHT TO CURE AND DISPUTE

To avoid disconnection, Client must remit the Amount Due and any applicable fees in cleared funds to Provider or reach an agreed payment arrangement before the Proposed Disconnect Date. If Client disputes the basis of this notice, Client must notify Provider in writing or by phone within the Notice Period to request a review. Provider will document receipt of such dispute and advise Client of any temporary hold, if applicable.

Provider Billing Contact:    Phone:

RECONNECTION CONDITIONS

Reconnection shall be conditioned upon payment in full of all outstanding charges, late fees, reconnection fee, and any required deposit. Provider may require an inspection or corrective action where safety hazards or unauthorized modifications are present. Reconnection will occur during normal business hours after Provider has received cleared payment and completed any required safety remediation.

CONFIDENTIALITY

Each party shall maintain the confidentiality of non-public account information disclosed in the course of resolving this notice, except as required by law or necessary to effectuate collection, disconnection, or reconnection. Client authorizes Provider to disclose limited account information to billing agents or contractors retained to perform reconnection or site work.

GOVERNING LAW

This Notice and any actions taken pursuant to it shall be governed by and construed in accordance with the laws of the jurisdiction in which the Service Address is located, without regard to conflict of law principles.

ENTIRE AGREEMENT

This Notice constitutes the entire written notice regarding the subject matter hereof and supersedes any prior oral or written communications solely to the extent they relate to the imminent disconnection. Any agreements reached to prevent disconnection must be evidenced in writing and signed by an authorized representative of Provider.

CERTIFICATIONS AND SPECIAL CONDITIONS

Customer asserts life-sustaining medical condition at this Service Address: If checked, Client must provide written certification from a licensed medical professional within the Notice Period. Failure to provide timely documentation does not preclude disconnection if the Amount Due is not cured.

Additional Comments:

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