<p> Central Missouri Community Action Non-Energy Payment Agreement </p><p>Date:______Phone #______</p><p>Name:______Account #:______</p><p>Social Security Number ______/______/______</p><p>Address:______</p><p>City, State and Zip:______</p><p>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.</p><p>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.</p><p>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.</p><p>______(Client’s Signature) (Date)</p><p>******************************************************************************************** ** This Bottom Portion is to be completed by the Utility Company ** Verification of Co-Payment</p><p>______Account #:______Vendor Name / Utility Company </p><p>Past-due Non-Electric $______</p><p>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)</p><p>Vendor / Utility Company Worker Name ______Today’s Date ______</p><p>Non-Energy Payment Agreement – copy in lime green </p>