Residential customers of PUCO-regulated electric, natural gas, and water utilities who are facing a disconnection for nonpayment may use this form to avoid a utility disconnect for up to 30 days.
The form may be used no more than three times in a rolling 12-month period.
The form must be completed by a licensed physician, physician assistant, clinical nurse specialist, certified nurse practitioner, certified nurse-midwife, or local board of health physician.
Download the 30-day medical certificate on this page.
