Central Missouri Counties Human Development Corporation

Central Missouri Community Action Non-Energy Payment Agreement

Date:______Phone #______

Name:______Account #:______

Social Security Number ______/______/______

Address:______

City, State and Zip:______

Your utility bill contains charges that CMCA cannot pay under our Energy Assistance Program. In order for you to receive Energy Assistance you must first pay for the non- energy charges.

If you do not make your non-energy payment, we will deny your application for Energy Assistance and we will not make any payment on your bill. You may re-apply, but you will still need to comply with our non-energy payment policy.

By signing below, I acknowledge that the above has been explained to me and that I understand my responsibilities in order to receive Energy Assistance from CMCA.

______(Client’s Signature) (Date)

******************************************************************************************** ** This Bottom Portion is to be completed by the Utility Company ** Verification of Co-Payment

______Account #:______Vendor Name / Utility Company

Past-due Non-Electric $______

Past-due Electric $______Disconnect Date ______(for Past-due Electric) Current Electric Due $______Disconnect Date ______(for Current Electric Due) Total Electric Due $______(Past-due Electric + Current Electric = Total)

Vendor / Utility Company Worker Name ______Today’s Date ______

Non-Energy Payment Agreement – copy in lime green