snap-benefits,"OF
PeachCare
1776
for Kids
Division of Family and
Children Services
Application for Benefits
(Complete this application and return it to your LOCAL COUNTY DFCS office.)
What Am I Applying For: (Check all that apply)
Food Stamps (Supplemental Nutrition Assistance Program (SNAP)
The Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps, is a federally
funded program that provides monthly benefits to low-income households to help pay for the cost of food.
The program also provides nutrition education to families to meet their food and nutritional needs and
employment and training opportunities to help families gain employment that leads to less dependence on
SNAP.
Temporary Assistance for Needy Families (TANF)
Temporary Assistance for Needy Families (TANF) provides temporary monthly cash payments, single cash
payments, or other support services, to strengthen eligible families with children. If you are the child's parent, or
the caretaker who would like to be included in the grant, we will require you to participate in a work program.
Grandparents Raising Grandchildren (GRG)
Grandparents Raising Grandchildren (GRG) will provide additional cash payments so that children can be
cared for in the homes of their grandparents. Applicants must apply for TANF to be eligible for GRG.
Refugee Cash Assistance
The Refugee Cash Assistance program provides financial assistance to refugee households who are not eligible
for the TANF program. The term refugee includes refugees, Cuban/Haitian Entrants, victims of human trafficking,
Amerasians, and unaccompanied refugee minors.
Medicaid
Medicaid offers medical coverage to elderly, blind or disabled adults, pregnant women, children, and families.
When you apply, we will look at all Medicaid programs and decide which ones you may be eligible to receive.
Please fill out the chart below about the applicant.
First Name
Middle Initial
Last Name
Suffix
David
Jesse
Roberts
Street Address Where You Live
Apt
123 Main St
City
State
Zip Code
Averill Park
NY
12018
Mailing Address (If different)
Main Telephone Number
Other Contact Number
Email Address (Optional)
E-mail Communication Yes or No (optional)
Texting: Yes or No (optional)
What is your Preferred Language?
If an interview is required, will you need an
interpreter? Yes
or
No
Americans with Disabilities Act: Request for Reasonable Modification & Communication Assistance (if applicable):
Do you have a disability that will require a Reasonable Modification or Communication Assistance? Yes No
(If yes, please describe the reasonable modification or Communication Assistance that you are requesting):
Sign Language interpreter
; TTY
; Large Print
; Electronic communication (email)
; Braille
; Video
Relay
; Cued Speech Interpreter
; Oral Interpreter
; Tactile Interpreter
;
Telephone call reminder of program
deadlines
; Telephonic signature (if applicable)
;
Face-to-face interview (home visit)
; Other:
Do you need this Reasonable Modification or Communication Assistance one-time or ongoing
? If
possible, briefly explain when and how long you need this modification or assistance?
Form 297 (Rev.09/20)
3
"
snap-benefits,"OF
PeachCare
1776
for Kids
Division of Family and
Children Services
Application for Benefits
(Complete this application and return it to your LOCAL COUNTY DFCS office.)
What Am I Applying For: (Check all that apply)
Food Stamps (Supplemental Nutrition Assistance Program (SNAP)
The Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps, is a federally
funded program that provides monthly benefits to low-income households to help pay for the cost of food.
The program also provides nutrition education to families to meet their food and nutritional needs and
employment and training opportunities to help families gain employment that leads to less dependence on
SNAP.
Temporary Assistance for Needy Families (TANF)
Temporary Assistance for Needy Families (TANF) provides temporary monthly cash payments, single cash
payments, or other support services, to strengthen eligible families with children. If you are the child's parent, or
the caretaker who would like to be included in the grant, we will require you to participate in a work program.
Grandparents Raising Grandchildren (GRG)
Grandparents Raising Grandchildren (GRG) will provide additional cash payments so that children can be
cared for in the homes of their grandparents. Applicants must apply for TANF to be eligible for GRG.
Refugee Cash Assistance
The Refugee Cash Assistance program provides financial assistance to refugee households who are not eligible
for the TANF program. The term refugee includes refugees, Cuban/Haitian Entrants, victims of human trafficking,
Amerasians, and unaccompanied refugee minors.
Medicaid
Medicaid offers medical coverage to elderly, blind or disabled adults, pregnant women, children, and families.
When you apply, we will look at all Medicaid programs and decide which ones you may be eligible to receive.
Please fill out the chart below about the applicant.
First Name
Middle Initial
Last Name
Suffix
Henry
Doe
Street Address Where You Live
Apt
123 Main St
City
State
Zip Code
Averill Park
NY
12018
Mailing Address (If different)
Main Telephone Number
Other Contact Number
Email Address (Optional)
E-mail Communication Yes or No (optional)
Texting: Yes or No (optional)
What is your Preferred Language?
If an interview is required, will you need an
interpreter? Yes
or
No
Americans with Disabilities Act: Request for Reasonable Modification & Communication Assistance (if applicable):
Do you have a disability that will require a Reasonable Modification or Communication Assistance? Yes No
(If yes, please describe the reasonable modification or Communication Assistance that you are requesting):
Sign Language interpreter
; TTY
; Large Print
; Electronic communication (email)
; Braille
; Video
Relay
; Cued Speech Interpreter
; Oral Interpreter
; Tactile Interpreter
;
Telephone call reminder of program
deadlines
; Telephonic signature (if applicable)
;
Face-to-face interview (home visit)
; Other:
Do you need this Reasonable Modification or Communication Assistance one-time or ongoing
? If
possible, briefly explain when and how long you need this modification or assistance?
Form 297 (Rev.09/20)
3
"
snap-benefits,"OF
PeachCare
1776
for Kids
Division of Family and
Children Services
Application for Benefits
(Complete this application and return it to your LOCAL COUNTY DFCS office.)
What Am I Applying For: (Check all that apply)
Food Stamps (Supplemental Nutrition Assistance Program (SNAP)
The Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps, is a federally
funded program that provides monthly benefits to low-income households to help pay for the cost of food.
The program also provides nutrition education to families to meet their food and nutritional needs and
employment and training opportunities to help families gain employment that leads to less dependence on
SNAP.
Temporary Assistance for Needy Families (TANF)
Temporary Assistance for Needy Families (TANF) provides temporary monthly cash payments, single cash
payments, or other support services, to strengthen eligible families with children. If you are the child's parent, or
the caretaker who would like to be included in the grant, we will require you to participate in a work program.
Grandparents Raising Grandchildren (GRG)
Grandparents Raising Grandchildren (GRG) will provide additional cash payments so that children can be
cared for in the homes of their grandparents. Applicants must apply for TANF to be eligible for GRG.
Refugee Cash Assistance
The Refugee Cash Assistance program provides financial assistance to refugee households who are not eligible
for the TANF program. The term refugee includes refugees, Cuban/ Haitian Entrants, victims of human trafficking,
Amerasians, and unaccompanied refugee minors.
Medicaid
Medicaid offers medical coverage to elderly, blind or disabled adults, pregnant women, children, and families.
When you apply, we will look at all Medicaid programs and decide which ones you may be eligible to receive.
Please fill out the chart below about the applicant.
First Name
Middle Initial
Last Name
Suffix
Jenny
Lee
Street Address Where You Live
Apt
123 Main St
City
State
Zip Code
Averill Park
NY
12018
Mailing Address (If different)
Main Telephone Number
Other Contact Number
Email Address (Optional)
E-mail Communication Yes or No (optional)
Texting: Yes or No (optional)
-
What is your Preferred Language?
If an interview is required, will you need an
interpreter? Yes
or
No
Americans with Disabilities Act: Request for Reasonable Modification & Communication Assistance (if applicable):
Do you have a disability that will require a Reasonable Modification or Communication Assistance? Yes
No
(If yes, please describe the reasonable modification or Communication Assistance that you are requesting):
Sign Language interpreter
; TTY
; Large Print
; Electronic communication (email)
; Braille
; Video
Relay
; Cued Speech Interpreter
; Oral Interpreter
; Tactile Interpreter
; Telephone call reminder of program
deadlines
; Telephonic signature (if applicable)
; Face-to-face interview (home visit)
; Other:
Do you need this Reasonable Modification or Communication Assistance one-time or ongoing
? If
possible, briefly explain when and how long you need this modification or assistance?
Form 297 (Rev.09/20)
3
"
snap-benefits,"OF
PeachCare
1776
for Kids
Division of Family and
Children Services
Application for Benefits
(Complete this application and return it to your LOCAL COUNTY DFCS office.)
What Am I Applying For: (Check all that apply)
Food Stamps (Supplemental Nutrition Assistance Program (SNAP)
The Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps, is a federally
funded program that provides monthly benefits to low-income households to help pay for the cost of food.
The program also provides nutrition education to families to meet their food and nutritional needs and
employment and training opportunities to help families gain employment that leads to less dependence on
SNAP.
Temporary Assistance for Needy Families (TANF)
Temporary Assistance for Needy Families (TANF) provides temporary monthly cash payments, single cash
payments, or other support services, to strengthen eligible families with children. If you are the child's parent, or
the caretaker who would like to be included in the grant, we will require you to participate in a work program.
Grandparents Raising Grandchildren (GRG)
Grandparents Raising Grandchildren (GRG) will provide additional cash payments so that children can be
cared for in the homes of their grandparents. Applicants must apply for TANF to be eligible for GRG.
Refugee Cash Assistance
The Refugee Cash Assistance program provides financial assistance to refugee households who are not eligible
for the TANF program. The term refugee includes refugees, Cuban/Haitian Entrants, victims of human trafficking,
Amerasians, and unaccompanied refugee minors.
Medicaid
Medicaid offers medical coverage to elderly, blind or disabled adults, pregnant women, children, and families.
When you apply, we will look at all Medicaid programs and decide which ones you may be eligible to receive.
Please fill out the chart below about the applicant.
First Name
Middle Initial
Last Name
Suffix
John
Doe
Street Address Where You Live
Apt
123 Main St
City
State
Zip Code
Averill Park
NY
12018
Mailing Address (If different)
Main Telephone Number
Other Contact Number
Email Address (Optional)
E-mail Communication Yes or No (optional)
Texting: Yes or No (optional)
What is your Preferred Language?
If an interview is required, will you need an
interpreter? Yes
or
No
Americans with Disabilities Act: Request for Reasonable Modification & Communication Assistance (if applicable):
Do you have a disability that will require a Reasonable Modification or Communication Assistance? Yes No
(If yes, please describe the reasonable modification or Communication Assistance that you are requesting):
Sign Language interpreter
; TTY
; Large Print
; Electronic communication (email)
; Braille
; Video
Relay
; Cued Speech Interpreter
; Oral Interpreter
; Tactile Interpreter
;
Telephone call reminder of program
deadlines
; Telephonic signature (if applicable)
;
Face-to-face interview (home visit)
; Other:
Do you need this Reasonable Modification or Communication Assistance one-time or ongoing
? If
possible, briefly explain when and how long you need this modification or assistance?
Form 297 (Rev.09/20)
3
"
snap-benefits,"OF
PeachCare
1776
for Kids
Division of Family and
Children Services
Application for Benefits
(Complete this application and return it to your LOCAL COUNTY DFCS office.)
What Am I Applying For: (Check all that apply)
Food Stamps (Supplemental Nutrition Assistance Program (SNAP)
The Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps, is a federally
funded program that provides monthly benefits to low-income households to help pay for the cost of food.
The program also provides nutrition education to families to meet their food and nutritional needs and
employment and training opportunities to help families gain employment that leads to less dependence on
SNAP.
Temporary Assistance for Needy Families (TANF)
Temporary Assistance for Needy Families (TANF) provides temporary monthly cash payments, single cash
payments, or other support services, to strengthen eligible families with children. If you are the child's parent, or
the caretaker who would like to be included in the grant, we will require you to participate in a work program.
Grandparents Raising Grandchildren (GRG)
Grandparents Raising Grandchildren (GRG) will provide additional cash payments so that children can be
cared for in the homes of their grandparents. Applicants must apply for TANF to be eligible for GRG.
Refugee Cash Assistance
The Refugee Cash Assistance program provides financial assistance to refugee households who are not eligible
for the TANF program. The term refugee includes refugees, Cuban/Haitian Entrants, victims of human trafficking,
Amerasians, and unaccompanied refugee minors.
Medicaid
Medicaid offers medical coverage to elderly, blind or disabled adults, pregnant women, children, and families.
When you apply, we will look at all Medicaid programs and decide which ones you may be eligible to receive.
Please fill out the chart below about the applicant.
First Name
Middle Initial
Last Name
Suffix
Olga
Martinez
Street Address Where You Live
Apt
123 Main St
City
State
Zip Code
Averill Park
NY
12018
Mailing Address (If different)
Main Telephone Number
Other Contact Number
Email Address (Optional)
E-mail Communication Yes or No (optional)
Texting: Yes or No (optional)
What is your Preferred Language?
If an interview is required, will you need an
interpreter? Yes
or
No
Americans with Disabilities Act: Request for Reasonable Modification & Communication Assistance (if applicable):
Do you have a disability that will require a Reasonable Modification or Communication Assistance? Yes No
(If yes, please describe the reasonable modification or Communication Assistance that you are requesting):
Sign Language interpreter
; TTY
; Large Print
; Electronic communication (email)
; Braille
; Video
Relay
; Cued Speech Interpreter
; Oral Interpreter
; Tactile Interpreter
;
Telephone call reminder of program
deadlines
; Telephonic signature (if applicable)
;
Face-to-face interview (home visit)
; Other:
Do you need this Reasonable Modification or Communication Assistance one-time or ongoing
? If
possible, briefly explain when and how long you need this modification or assistance?
Form 297 (Rev.09/20)
3
"
snap-benefits,"OF
PeachCare
1776
for Kids
Division of Family and
Children Services
Application for Benefits
(Complete this application and return it to your LOCAL COUNTY DFCS office.)
What Am I Applying For: (Check all that apply)
Food Stamps (Supplemental Nutrition Assistance Program (SNAP)
The Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps, is a federally
funded program that provides monthly benefits to low-income households to help pay for the cost of food.
The program also provides nutrition education to families to meet their food and nutritional needs and
employment and training opportunities to help families gain employment that leads to less dependence on
SNAP.
Temporary Assistance for Needy Families (TANF)
Temporary Assistance for Needy Families (TANF) provides temporary monthly cash payments, single cash
payments, or other support services, to strengthen eligible families with children. If you are the child's parent, or
the caretaker who would like to be included in the grant, we will require you to participate in a work program.
Grandparents Raising Grandchildren (GRG)
Grandparents Raising Grandchildren (GRG) will provide additional cash payments so that children can be
cared for in the homes of their grandparents. Applicants must apply for TANF to be eligible for GRG.
Refugee Cash Assistance
The Refugee Cash Assistance program provides financial assistance to refugee households who are not eligible
for the TANF program. The term refugee includes refugees, Cuban/Haitian Entrants, victims of human trafficking,
Amerasians, and unaccompanied refugee minors.
Medicaid
Medicaid offers medical coverage to elderly, blind or disabled adults, pregnant women, children, and families.
When you apply, we will look at all Medicaid programs and decide which ones you may be eligible to receive.
Please fill out the chart below about the applicant.
First Name
Middle Initial
Last Name
Suffix
Sam
Doe
Street Address Where You Live
Apt
123 Main St
City
State
Zip Code
Averill Park
NY
12018
Mailing Address (If different)
Main Telephone Number
Other Contact Number
Email Address (Optional)
E-mail Communication Yes or No (optional)
Texting: Yes or No (optional)
What is your Preferred Language?
If an interview is required, will you need an
interpreter? Yes
or
No
Americans with Disabilities Act: Request for Reasonable Modification & Communication Assistance (if applicable):
Do you have a disability that will require a Reasonable Modification or Communication Assistance? Yes No
(If yes, please describe the reasonable modification or Communication Assistance that you are requesting):
Sign Language interpreter
; TTY
; Large Print
; Electronic communication (email)
; Braille
; Video
Relay
; Cued Speech Interpreter
; Oral Interpreter
; Tactile Interpreter
;
Telephone call reminder of program
deadlines
; Telephonic signature (if applicable)
;
Face-to-face interview (home visit)
; Other:
Do you need this Reasonable Modification or Communication Assistance one-time or ongoing
? If
possible, briefly explain when and how long you need this modification or assistance?
Form 297 (Rev.09/20)
3
"
snap-benefits,"OF
PeachCare
1776
for Kids
Division of Family and
Children Services
Application for Benefits
(Complete this application and return it to your LOCAL COUNTY DFCS office.)
What Am I Applying For: (Check all that apply)
Food Stamps (Supplemental Nutrition Assistance Program (SNAP)
The Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps, is a federally
funded program that provides monthly benefits to low-income households to help pay for the cost of food.
The program also provides nutrition education to families to meet their food and nutritional needs and
employment and training opportunities to help families gain employment that leads to less dependence on
SNAP.
Temporary Assistance for Needy Families (TANF)
Temporary Assistance for Needy Families (TANF) provides temporary monthly cash payments, single cash
payments, or other support services, to strengthen eligible families with children. If you are the child's parent, or
the caretaker who would like to be included in the grant, we will require you to participate in a work program.
Grandparents Raising Grandchildren (GRG)
Grandparents Raising Grandchildren (GRG) will provide additional cash payments so that children can be
cared for in the homes of their grandparents. Applicants must apply for TANF to be eligible for GRG.
Refugee Cash Assistance
The Refugee Cash Assistance program provides financial assistance to refugee households who are not eligible
for the TANF program. The term refugee includes refugees, Cuban/Haitian Entrants, victims of human trafficking,
Amerasians, and unaccompanied refugee minors.
Medicaid
Medicaid offers medical coverage to elderly, blind or disabled adults, pregnant women, children, and families.
When you apply, we will look at all Medicaid programs and decide which ones you may be eligible to receive.
Please fill out the chart below about the applicant.
First Name
Middle Initial
Last Name
Suffix
Susmitha
Doe
Street Address Where You Live
Apt
123 Main St
City
State
Zip Code
Averill Park
NY
12018
Mailing Address (If different)
Main Telephone Number
Other Contact Number
Email Address (Optional)
E-mail Communication Yes or No (optional)
Texting: Yes or No (optional)
What is your Preferred Language?
If an interview is required, will you need an
interpreter? Yes
or
No
Americans with Disabilities Act: Request for Reasonable Modification & Communication Assistance (if applicable):
Do you have a disability that will require a Reasonable Modification or Communication Assistance? Yes No
(If yes, please describe the reasonable modification or Communication Assistance that you are requesting):
Sign Language interpreter
; TTY
; Large Print
; Electronic communication (email)
; Braille
; Video
Relay
; Cued Speech Interpreter
; Oral Interpreter
; Tactile Interpreter
;
Telephone call reminder of program
deadlines
; Telephonic signature (if applicable)
;
Face-to-face interview (home visit)
; Other:
Do you need this Reasonable Modification or Communication Assistance one-time or ongoing
? If
possible, briefly explain when and how long you need this modification or assistance?
Form 297 (Rev.09/20)
3
"
snap-benefits,"OFS 4APP
Louisiana Department of Children and
OFFICE USE ONLY
Rev. 08/19
Family Services
05/18 Issue Obsolete
Date Received
Il
Application for Assistance
Assigned to
Is an EBT card needed?
Yes
No
Check only those programs for which you are applying:
Family Independence Temporary Assistance Program (FITAP)
Kinship Care Subsidy Program (KCSP)
Supplemental Nutrition Assistance Program (SNAP) (formerly the Food Stamp Program)
You can begin to apply and establish your application date by filling in your name, address and signature below
and give this form to us today. It will help us to process your application faster if you also give us a telephone
number where you can be reached during the day and provide a copy of a photo ID or other proof of identity.
Can you read and understand English? (¿ Puede leer usted y poder comprender ingles?)
Yes (Sí)
No
If No, what language can you read and understand? Si no, qué idioma le puede lee y comprende?)
Lee
Jane
123-45-6789
(Last Name)
(First Name)
(Middle Name)
Social Security Number
1234 5th Avenue
Baton Rouge LA
70801
Street or Rural Route
Apt. or Lot#
City and State
Zip Code
Phone#
Mailing Address if different from above:
I certify under penalty of perjury, the truth of the information contained in this application, including the information concerning
citizenship and alien status of the members applying for benefits.
janslee
Your Signature
What if you need SNAP benefits right away?
We may be able to get SNAP benefits to you within 7 days of the date you apply if you qualify. You may qualify if:
The total amount of money you have received or expect to receive this month is less than $150 and you
have $100 or less in liquid resources such as cash, savings or checking accounts; or
Your household's rent/mortgage and utilities are more than your total income and resources; or
Your household includes migrant or seasonal farm workers.
If any of the above describes your household, answer the following questions:
1.
What is the total amount of money that your household will receive this month?
Include money from all sources such as earned income, contributions, Social
Security, SSI, VA, etc.
$
2.
How much money does your household have in liquid resources? Include cash on
hand, checking accounts, savings accounts, etc.
$
3.
How much is your household's monthly rent or mortgage?
$
4.
Do you pay for utilities, such as electricity, gas, water, etc.?
Yes
No
5.
Do you pay utility costs for heating or air conditioning?
Yes
No
6.
Do you pay telephone expenses?
Yes
No
7.
Is anyone in your household a migrant or seasonal farm worker?
Yes
No
OFS 4APP - Rev. 08/19
A1
12/17 Issue Obsolete
"
snap-benefits,"NEBRASKA
Division of Children and Family Services
Good Life. Great Mission.
Application for Economic Assistance Benefits
DEPT. OF HEALTH AND HUMAN SERVICES
Days to Process for SNAP: Those eligible for expedited service will receive SNAP benefits within 7 days from when DHHS received
the application. Those not eligible for expedited service may receive SNAP benefits within 30 days from when DHHS received the
application. Benefits will be determined from the date the application is received by DHHS.
(1) Programs Needed
Food & Energy
Refugee
Family & Children
Aged & Disabled
Which programs do you want
SNAP
LIHEAP
LIHWAP
RRP
ADC
CC
EA
SSCF
AABD
PAS
SSAD
SDP
to apply for?
Please note this is not an application for Medicaid coverage or services. Contact 1-855-632-7633 to apply for Medicaid
Cards Needed
(2) Do you have a Nebraska Electronic Benefits Transfer (EBT) card for Supplemental
Yes
No, I will need an EBT card.
Nutrition Assistance Program (SNAP) Benefits?
(3) Do you have a Nebraska US Bank ReliaCard for LIHEAP, RRP, ADC, and/or AABD?
Yes
No, I will need a ReliaCard.
APPLICANT INFORMATION/HEAD OF HOUSEHOLD: If your household has more than one parent, you must tell ACCESSNebraska which parent should be
designated as ""Head of Household. DHHS WILL USE THE PERSON LISTED HERE AS THE HEAD OF HOUSEHOLD.
(4) First Name:
MI
Last Name:
Social Security Number:
Date of Birth:
Pollard
333-33-3333
Morris
06/02/1970
(5) Do you need an interpreter?
Yes
No
If yes, what language do you speak?
(6) Where do you live?
House - rent/own/mortgage
Apartment/Duplex/Triplex
Rent a Room
Homeless
Room and Board
Treatment Center
Assisted Living
Shelter
Nursing Home
Group home/Foster Care/Child Care Institution/Adult Family home
Center for Developmentally Disabled
Other:
(7) Facility or shelter name (if applies):
(8) Is this public/subsidized housing?
Yes
No
(9) Is anyone in the household a boarder?
Yes
No
(10)
Is the applicant a boarder?
Yes
No
Boarder:
An
individual
who either lives in a commercial boarding house or lives with a household and pays reasonable compensation in cash for meals and
lodging. A boarder is not considered a member of a participating household and his/her income and resources are not considered available to the household.
(11) Physical Address (Street, Apt/Unit #):
City:
State:
Zip:
Apt #101 Neighbourhood housing
NE
68007
Omaha
(12) Mailing Address if Different (Street, PO Box, Apt/Unit #):
City:
State:
Zip:
(13) Do you have someone who needs to be listed as the ""In Care Of"" (c/o)?
If so, who:
Yes
No
(14) Do you need to have your mail sent to general delivery?
If so, please provide the City/State or ZIP:
Yes
No
(15) Prior Address (Street, Apt/Unit #):
City:
State:
Zip:
(16) If you are not registered to vote where you live now, would you like to apply to register to vote today?
Yes
No
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.
Any
citizen
in
the
State of Nebraska who has met the voter registration requirements and applies for economic assistance must be provided the opportunity to register
to
vote.
If
you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the
application form in private. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.
Please
note
that
the
information and office to which application was made will remain confidential and be used only for voter registration purposes. If you believe
someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in
applying
to
register
to
vote,
or
your right to choose your own political party or other political preference, you may file a complaint with the Nebraska Secretary of State, 1221 N Street,
Suite 103, PO BOX 94608, Lincoln NE 68509-4608, 402-471-2555.
/ state under penalty of perjury that / completed the application to the best of my knowledge and my answers are true and correct including information concerning
citizenship and alien status of the members applying for benefits. / authorize the release of information to DHHS. The requested information will be used only
in administration of economic assistance programs and will not be released to any other person or agency outside of DHHS. / understand DHHS may release
information to another agency when services of that agency have been requested or when the objective in obtaining the information is to provide services to me
or my household. / read, understand and agree to the ""What Should / Know"" section located on the last pages of this document.
(17) Applicant or Authorized Representative's Signature:
Date:
morrispollard
You or your Authorized Representative may submit an application with only your name, address, and signature on this page.
If you are applying for Supplemental Nutrition Assistance Program (SNAP) and are receiving or have applied for Supplemental Security
Income (SSI) while in an institution, the date of the application will be the date of the release from the institution.
By applying, you may be eligible to receive information on services to assist families with children so that children may continue to be cared for in their home.
Please call the child abuse/neglect hotline for additional information at 800-652-1999.
EA-117 Rev. 2/2022
Page 3 of 23
"
snap-benefits,"Washington State
Department of Social
Application for Food and Cash Assistance
& Health Services
Ask us if you need help filling out this form.
Transforming lives
1. FIRST NAME MIDDLE INITIAL LAST NAME
SIGNATURE OF APPLICANT OR
2. CLIENT IDENTIFICATION NUMBER
AUTHORIZED REPRESENTATIV
(IF KNOWN)
(REQUIRED)
Patty Campbell
pattycambell
3. STREET ADDRESS WHERE YOULIVE
CIT Y
STATE ZIP CODE
4. PRIMARY PHONE NUMBER
CELL
HOME
MESSAGE
1111 1st Street
Bellevue
WA
98051
5. MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP CODE
6. SECONDARY PHONE NUMBER(S)
CELL
HOME
MESSAGE
8. I am applying for (check all that apply):
7. EMAIL ADDRESS
Cash
Food
Child care
9. I or someone in my household (check all that apply):
Are in a domestic violence situation
Have a disability
Can't work because of health problems
Are pregnant; name:
due date:
10. How much money do you expect your household to get this month?
$
11. How much money does your household have in cash and bank accounts?
$
12. How much does your household pay for rent or mortgage?
$
13. What utilities does your household pay for?
Heating/cooling
Telephone
Other:
14. Is anyone in your household a seasonal or migrant farm worker?
Yes
No
15. If applying for food assistance, howmany people in your household do you buy and prepare food for?
16. If applying for child care, what activity do you need care for (check all that apply)?
Work
School
WorkFirst
Basic Food Employment and Training (BFET)
FOR OFFICE USE ONLY - Household eligible for expedited service:
Yes
No Screener's Initials:
Date:
17.
I need an interpreter. I speak:
or
sign; translate my letters into:
18. List everyone in your household even if you are not applying for them (attach additional sheets, if necessary).
CHECK IF
OPTIONAL FOR NON-APPLICANTS
NAME
HOW IS THIS
YOU WANT
TRIBE NAME
(FIRST,
PERSON
DATE OF
SOCIAL
CHECK
GENDER
BENEFITS
RACE (SEE
MIDDLE,
RELATED TO
BIRTH
SECURITY
IF U.S.
SAMPLES
(For American
FOR THIS
Indians, Alaska
LAST)
YOU?
NUMBER
CITIZEN
PERSON
BELOW)
Natives)
Myself
19. My ethnic background is Hispanic or Latino:
Yes
No
Race and Ethnic background information is voluntary and will not affect eligibility or benefit amounts. This
information is used to assure program benefits are distributed without regard to race, color, or national origin. For
Food Assistance the USDA requires us to answer for you if no information is provided. Race examples: White,
Black or African American, Asian, Native Hawaiian, Pacific Islander, American Indian, Alaska Native, or any
combination of races.
DSHS 14-001 (REV. 07/2020)
Page 3
Barcode label
14001
"
snap-benefits,"NH Department of Health and Human Services (DHHS)
BFA Form 800
Bureau of Family Assistance (BFA)
www.dhhs.nh.gov/dfa/index.htm
10/20
APPLICATION FOR ASSISTANCE
A. Please tell us about who you are and where you live.
Full Legal Name:
Russel Barron
Primary Language:
English
Current Place of Residence:
Own home
Nursing Facility
Adult Family Home
Assisted Living
Congregate Housing
Homeless
Hospital
Hotel/Motel
Residential Care Facility
Other
Street Address: Apt # 201 Community Housing
Mailing Address:
(if different)
City/State/Zip:
Derry/NH/03038
Home Phone:
Work Phone:
Cell/Message:
E-Mail Address:
I do not have an E-Mail address
Does anyone in your family have Medicare Part A or B?
Y
N
Why do you need our help?
Information Supplier:
(if different from applicant)
Name
Address
Phone #
B.
Please tell us about the people you live with. Start with yourself and list ALL of the people living with
you. You do not have to give the Social Security Number or citizenship status of any individual who is not applying for
assistance.
Full Legal Name
SSN
DOB
Relation to you
U.S. Citizen?
Student (Yes or No.
RID (BFA Use
If Yes, put grade too)
Only)
1.
SELF
Y
N
2.
Y
N
3.
Y
N
4.
Y
N
5.
Y
N
6.
Y
N
C. I want to apply for: (TYPES OF ASSISTANCE REQUESTED)
ALL PROGRAMS
Cash
SNAP
Child Care
Home and Community-Based Care (HCBC)
Medicare Savings Programs (MSP) [QMB/QWDI/SLMB/SLMB135]
Nursing Facility (NF) Services - Facility Name:
Medical Assistance - if you need Medical Assistance for a child, pregnant women, or parent/caretaker relative of a child, you must also
complete the insert entitled Medical Assistance for Children, Pregnant Women, and Parent/Caretaker Relatives Insert
D. The following information is collected to be sure that everyone is served fairly without regard to race, color, or
national origin. Your answers are voluntary. The information provided will not affect your eligibility or benefit
amount. For ethnicity, please select one response. For race, please select all that apply.
Ethnicity:
Are you Hispanic or Latino?
Yes
No
Native Hawaiian or Other Pacific
Race:
Are you:
White?
Y
N
Asian?
Y
N
Islander?
Y
N
Black or African American?
Y
N
American Indian or Alaskan Native?
Y
N
AGENCY USE ONLY:
RFA#
Case #
Forms Given:
725
177
Cash
OPEN
CLOSE
DENY
DATE:
DO:
SNAP
OPEN
CLOSE
DENY
DATE:
DO:
MA
OPEN
CLOSE
DENY
DATE:
DO:
CM/MCPW
OPEN
CLOSE
DENY
DATE:
DO:
Child Care
OPEN
CLOSE
DENY
DATE:
DO:
EBT Card Status:
None
Active
Bad Address
Deactivated/Cancelled
Undelivered
SR 20-02
(N/A)
"
snap-benefits,"Application for Benefits
Please print clearly and answer questions completely and honestly. Thank you!
202
Revised 10/2018
1. Tell us about you, the person applying.
First name, middle name, last name and suffix (Jr., Sr., III, etc.)
Date of birth (mm/dd/yyyy)
05/01/1966
Saundra Fields
Social Security number
Phone number where you can be reached
Town where you live
222-22-2222
(
)
-
Mailing address, line 1
Apartment or suite number
333 Nice Cove Street
Mailing address, line 2 (if applicable, include an ""in-care-of person here)
City
State
Zip code
Bridgewater
VA
05034
Physical or home address
Check if same as mailing address
Apartment or suite number
City
State
Zip code
2. Which programs are you applying for?
Check off each program you are applying for (you can apply for more than one).
3SquaresVT:
Reach Up:
Fuel Assistance:
Essential Person:
Helps people
Provides support
Helps people
Helps people to
to buy food.
to households
to heat their
+
pay for essential,
with children.
homes
live-in care at home
As you complete this application, look for the symbols above. You only need to answer the questions that show the symbols of
the programs you are applying for. If you are not sure which programs you want, please answer all of the questions.
3. Are you interested in these additional services?
WIC: If you have a child under five, or are a pregnant or nursing woman, you may qualify for additional help with food, health
screening, and nutrition education. If so, would you like someone from the WIC program to contact you?
Yes
No
To learn more about the WIC program, you can also call toll free 1-800-464-4343.
Voter Registration: If you are not registered to vote where you live now, would you like a voter registration application? If you
do not check either box, you will be considered to have decided not to register to vote at this time.
Yes
No
Applying to register or declining to register to vote will not affect your eligibility for benefits or amount granted to you by ESD. If you
would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help
is yours. You may fill out the application form in private. If you believe that someone has interfered with your right to register or
to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to
choose your own political party or other political preference, you may file a complaint with the Secretary of State's Office at
128 State Street, Montpelier, VT 05633-1101, or call 1-802-828-2363, or 1-800-439-8683 (toll free).
SIGN HERE. UNSIGNED APPLICATIONS WILL NOT BE PROCESSED. THEY WILL BE RETURNED.
/ give my word, under penalty of perjury, that the information in this application is correct and complete to the
best of my knowledge and belief, including information about citizenship and alien status. / have read and
/
understand my Rights & Responsibilities on pages 17-18, and / agree to them.
sandrafields
Date
Signature of Applicant or Representative (see page 15 for definition)
Page 1
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"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
January 27, 2020
Amount Due:
$300.20
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about March 23, 2020
EBPP
Account Summary
Previous invoice
$512.58
Payments received as of 01/24/20
-512.58
Residential
Balance forward
0.00
Energy charges
299.37
Residential consumer
Miscellaneous charges
0.83
discount $ 2.31
See details beginning
Payment due upon receipt.
$300.20
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
02/19/20
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$300.20
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
401004107613300000300200000030020
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
February 26, 2020
Amount Due:
$314.24
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about March 23, 2020
EBPP
Account Summary
Previous invoice
$300.20
Payments received as of 02/25/20
-300.20
Residential
Balance forward
0.00
Energy charges
313.41
Residential consumer
Miscellaneous charges
0.83
discount $ 1.65
See details beginning
Payment due upon receipt.
$314.24
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
03/20/20
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$314.24
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
00100410761330000031424000003142
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
March 26, 2020
Amount Due:
$300.82
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about May 21, 2020
EBPP
Account Summary
Previous invoice
$314.24
Payments received as of 03/25/20
-314.24
Residential
Balance forward
0.00
Energy charges
299.99
Residential consumer
Miscellaneous charges
0.83
discount $ 1.41
See details beginning
Payment due upon receipt.
$300.82
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
04/18/20
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$300.82
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
4401004107613300000300820000030082
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
April 28, 2020
Amount Due:
$206.74
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about May 21, 2020
EBPP
Account Summary
Previous invoice
$300.82
Payments received as of 04/27/20
-300.82
Residential
Balance forward
0.00
Energy charges
205.91
Residential consumer
Miscellaneous charges
0.83
discount $ 1.32
See details beginning
Payment due upon receipt.
$206.74
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
05/21/20
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$206.74
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
6010041076133000002067400000206 74
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
May 28, 2020
Amount Due:
$9.62
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 5
Next Scheduled Read Date: On or about July 23, 2020
EBPP
Account Summary
Previous invoice
$206.74
Total adjustments
-206.74
Residential
Payments received as of 05/27/20
-206.74
Balance forward
$-206.74
Residential consumer
Energy charges
215.53
discount $ 1.76
Miscellaneous charges
0.83
See details beginning
on page 3
Payment due upon receipt.
$9.62
See messages on page 2
To avoid a 1.5% late payment charge, please ensure payment is
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
06/20/20
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$9.62
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
701004107613300000216360000000961
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
June 25, 2021
Amount Due:
$292.90
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about July 23, 2021
EBPP
Account Summary
Previous invoice
$568.04
Payments received as of 06/24/21
-568.04
Residential
Balance forward
0.00
Energy charges
291.98
Residential consumer
Miscellaneous charges
0.92
discount $ 4.35
See details beginning
Payment due upon receipt.
$292.90
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
07/18/21
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$292.90
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
801004107613300000292900000029290
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
July 27, 2020
Amount Due:
$464.61
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about September 23, 2020
EBPP
Account Summary
Previous invoice
$161.91
Payments received as of 07/24/20
0.00
Residential
Balance forward
$161.91
Energy charges
301.87
Residential consumer
Miscellaneous charges
0.83
discount $ 5.20
See details beginning
Payment due upon receipt.
$464.61
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
08/19/20
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$464.61
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
3010041076133000003027000000464L
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
August 27, 2020
Amount Due:
$196.64
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about September 23, 2020
EBPP
Account Summary
Previous invoice
$464.61
Payments received as of 08/26/20
-464.61
Residential
Balance forward
0.00
Energy charges
195.81
Residential consumer
Miscellaneous charges
0.83
discount $ 2.99
See details beginning
Payment due upon receipt.
$196.64
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
09/19/20
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$196.64
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
40100410761330000019664000001966
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
September 25, 2020
Amount Due:
$224.18
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about November 20, 2020
EBPP
Account Summary
Previous invoice
$196.64
Payments received as of 09/24/20
-196.64
Residential
Balance forward
0.00
Energy charges
223.35
Residential consumer
Miscellaneous charges
0.83
discount $ 2.99
See details beginning
Payment due upon receipt.
$224.18
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
10/18/20
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$224.18
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
601004107613300000224180000022418
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
October 27, 2020
Amount Due:
$192.51
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about November 20, 2020
EBPP
Account Summary
Previous invoice
$224.18
Payments received as of 10/26/20
-224.18
Residential
Balance forward
0.00
Energy charges
191.68
Residential consumer
Miscellaneous charges
0.83
discount $ 2.10
See details beginning
Payment due upon receipt.
$192.51
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
11/19/20
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$192.51
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
601004107613300000192510000019251
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
November 23, 2020
Amount Due:
$109.05
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about January 22, 2021
EBPP
Account Summary
Previous invoice
$192.51
Payments received as of 11/20/20
-192.51
Residential
Balance forward
0.00
Energy charges
108.22
Residential consumer
Miscellaneous charges
0.83
discount $ 0.39
See details beginning
Payment due upon receipt.
$109.05
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
12/16/20
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$109.05
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
601004107613300000109050000010905
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
December 28, 2020
Amount Due:
$310.08
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about January 22, 2021
EBPP
Account Summary
Previous invoice
$109.05
Payments received as of 12/24/20
-109.05
Residential
Balance forward
0.00
Energy charges
309.16
Residential consumer
Miscellaneous charges
0.92
discount $ 0.72
See details beginning
Payment due upon receipt.
$310.08
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
01/20/21
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$310.08
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
January 27, 2021
Amount Due:
$367.78
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about March 23, 2021
EBPP
Account Summary
Previous invoice
$310.08
Payments received as of 01/26/21
-310.08
Residential
Balance forward
0.00
Energy charges
366.86
Residential consumer
Miscellaneous charges
0.92
discount $ 0.99
See details beginning
Payment due upon receipt.
$367.78
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
02/19/21
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$367.78
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
01004107613300000367780000036778
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
February 24, 2021
Amount Due:
$175.23
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about March 23, 2021
EBPP
Account Summary
Previous invoice
$367.78
Payments received as of 02/23/21
-367.78
Residential
Balance forward
0.00
Energy charges
174.31
Residential consumer
Miscellaneous charges
0.92
discount $ 0.48
See details beginning
Payment due upon receipt.
$175.23
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
03/19/21
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$175.23
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
401004107613300000175230000017523
"
utility-bill,"JESSE ROBERTS
89
NYSEG
Account Number:
1004-1076-133
Statement Date:
March 26, 2021
Amount Due:
$232.19
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about May 21, 2021
EBPP
Account Summary
Previous invoice
$175.23
Payments received as of 03/25/21
-175.23
Residential
Balance forward
0.00
Energy charges
231.27
Residential consumer
Miscellaneous charges
0.92
discount $ 0.59
See details beginning
Payment due upon receipt.
$232.19
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
04/18/21
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$232.19
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
0100410761330000023219000002321
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
April 27, 2021
Amount Due:
$217.27
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about May 21, 2021
EBPP
Account Summary
Previous invoice
$232.19
Payments received as of 04/26/21
-232.19
Residential
Balance forward
0.00
Energy charges
216.35
Residential consumer
Miscellaneous charges
0.92
discount $ 0.74
See details beginning
Payment due upon receipt.
$217.27
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
05/20/21
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$217.27
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
.01004107613300000217270000021727
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
May 24, 2021
Amount Due:
$568.04
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about July 23, 2021
EBPP
Account Summary
Previous invoice
$217.27
Payments received as of 05/21/21
0.00
Residential
Balance forward
$217.27
Energy charges
349.85
Residential consumer
Miscellaneous charges
0.92
discount $ 3.26
See details beginning
Payment due upon receipt.
$568.04
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
06/16/21
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$568.04
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
501004107613300000350770000056804
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
June 25, 2021
Amount Due:
$292.90
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about July 23, 2021
EBPP
Account Summary
Previous invoice
$568.04
Payments received as of 06/24/21
-568.04
Residential
Balance forward
0.00
Energy charges
291.98
Residential consumer
Miscellaneous charges
0.92
discount $ 4.35
See details beginning
Payment due upon receipt.
$292.90
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
07/18/21
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$292.90
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
801004107613300000292900000029290
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
August 26, 2021
Amount Due:
$207.22
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about September 22, 2021
EBPP
Account Summary
Previous invoice
$-44.41
Payments received as of 08/25/21
0.00
Residential
Balance forward
$-44.41
Energy charges
250.71
Residential consumer
Miscellaneous charges
0.92
discount $ 3.90
See details beginning
Payment due upon receipt.
$207.22
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
09/18/21
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$207.22
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
201004107613300000251630000020722
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
August 26, 2021
Amount Due:
$207.22
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about September 22, 2021
EBPP
Account Summary
Previous invoice
$-44.41
Payments received as of 08/25/21
0.00
Residential
Balance forward
$-44.41
Energy charges
250.71
Residential consumer
Miscellaneous charges
0.92
discount $ 3.90
See details beginning
Payment due upon receipt.
$207.22
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
09/18/21
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$207.22
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
201004107613300000251630000020722
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
October 27, 2021
Amount Due:
$208.15
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about November 22, 2021
EBPP
Account Summary
Previous invoice
$25.45
Payments received as of 10/26/21
-25.45
Residential
Balance forward
0.00
Energy charges
207.23
Residential consumer
Miscellaneous charges
0.92
discount $ 3.32
See details beginning
Payment due upon receipt.
$208.15
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
11/19/21
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$208.15
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
401004107613300000208150000020815
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
November 23, 2021
Amount Due:
$101.03
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about January 24, 2022
EBPP
Account Summary
Previous invoice
$208.15
Payments received as of 11/22/21
-208.15
Residential
Balance forward
0.00
Energy charges
100.11
Residential consumer
Miscellaneous charges
0.92
discount $ 0.73
See details beginning
Payment due upon receipt.
$101.03
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
12/16/21
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$101.03
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
December 28, 2021
Amount Due:
$385.63
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about January 24, 2022
EBPP
Account Summary
Previous invoice
$101.03
Payments received as of 12/27/21
-101.03
Residential
Balance forward
0.00
Energy charges
384.71
Residential consumer
Miscellaneous charges
0.92
discount $ 2.44
See details beginning
Payment due upon receipt.
$385.63
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
01/20/22
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$385.63
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
601004107613300000385630000038563
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1004-1076-133
Statement Date:
December 28, 2021
Amount Due:
$385.63
Service Address: 193 EDGEWOOD DR, AVERILL PARK NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about January 24, 2022
EBPP
Account Summary
Previous invoice
$101.03
Payments received as of 12/27/21
-101.03
Residential
Balance forward
0.00
Energy charges
384.71
Residential consumer
Miscellaneous charges
0.92
discount $ 2.44
See details beginning
Payment due upon receipt.
$385.63
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
10041076133
Late Fee After
01/20/22
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$385.63
Amount Paid
$
JESSE ROBERTS
193 EDGEWOOD DR
AVERILL PARK NY 12018-2510
Please do not write below this line.
601004107613300000385630000038563
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1234-5678-912
Statement Date:
December 28, 2021
Amount Due:
$385.63
Service Address: 123 MAIN ST, AVERILL PARK, NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about January 24, 2022
EBPP
Account Summary
Previous invoice
$101.03
Payments received as of 12/27/21
-101.03
Residential
Balance forward
0.00
Energy charges
384.71
Residential consumer
Miscellaneous charges
0.92
discount $ 2.44
See details beginning
Payment due upon receipt.
$385.63
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
12345678912
Late Fee After
01/20/22
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$385.63
Amount Paid
$
JESSE ROBERTS
123 MAIN ST
AVERILL PARK NY 12018-2510
Please do not write below this line.
601004107613300000385630000038563
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1234-5678-912
Statement Date:
December 28, 2021
Amount Due:
$385.63
Page 1 of 4
Next Scheduled Read Date: On or about January 24, 2022
EBPP
Account Summary
Previous invoice
$101.03
Payments received as of 12/27/21
-101.03
Residential
Balance forward
0.00
Energy charges
384.71
Residential consumer
Miscellaneous charges
0.92
discount $ 2.44
See details beginning
Payment due upon receipt.
$385.63
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
12345678912
Late Fee After
01/20/22
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$385.63
Amount Paid
$
JESSE ROBERTS
123 MAIN ST
AVERILL PARK NY 12018
Please do not write below this line.
601004107613300000385630000038563
"
utility-bill,"JESSE ROBERTS
NYSEG
Account Number:
1234-5678-912
Statement Date:
December 28, 2021
Amount Due:
$385.63
Service Address: 123 COLE LN, TROY, NY 12180
Page 1 of 4
Next Scheduled Read Date: On or about January 24, 2022
EBPP
Account Summary
Previous invoice
$101.03
Payments received as of 12/27/21
-101.03
Residential
Balance forward
0.00
Energy charges
384.71
Residential consumer
Miscellaneous charges
0.92
discount $ 2.44
See details beginning
Payment due upon receipt.
$385.63
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
12345678912
Late Fee After
01/20/22
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$385.63
Amount Paid
$
JESSE ROBERTS
123 COLE LN
TROY NY 12180
Please do not write below this line.
601004107613300000385630000038563
"
utility-bill,"SAM DOE
2
NYSEG
Account Number:
1234-5678-912
Statement Date:
December 28, 2021
Amount Due:
$385.63
Service Address: 123 MAIN ST, AVERILL PARK, NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about January 24, 2022
EBPP
Account Summary
Previous invoice
$101.03
Payments received as of 12/27/21
-101.03
Residential
Balance forward
0.00
Energy charges
384.71
Residential consumer
Miscellaneous charges
0.92
discount $ 2.44
See details beginning
Payment due upon receipt.
$385.63
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
12345678912
Late Fee After
01/20/22
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$385.63
Amount Paid
$
SAM DOE
123 MAIN ST
AVERILL PARK NY 12018
Please do not write below this line.
601004107613300000385630000038563
"
utility-bill,"SUSMITHA DOE
NYSEG
Account Number:
1234-5678-912
Statement Date:
December 28, 2021
Amount Due:
$385.63
Service Address: 123 MAIN ST, AVERILL PARK, NY 12018
Page 1 of 4
Next Scheduled Read Date: On or about January 24, 2022
EBPP
Account Summary
Previous invoice
$101.03
Payments received as of 12/27/21
-101.03
Residential
Balance forward
0.00
Energy charges
384.71
Residential consumer
Miscellaneous charges
0.92
discount $ 2.44
See details beginning
Payment due upon receipt.
$385.63
on page 3
To avoid a 1.5% late payment charge, please ensure payment is
See messages on page 2
received by the date displayed below.
Think of the minutes, money and
natural resources you'll save by doing
business online or by phone 24/7.
Visit nyseg.com to:
View and pay your bill online
Submit and view meter readings
Enroll and manage budget billing
Enroll in Autopay
Call our self-service line at
1.800.600.2275 for billing information,
provide a meter reading and to pay by
phone.
Add $1, $2, or $5 to your payment to
make a tax-deductible donation to
NYSEG and RG&E Project SHARE
Heating Fund. Learn more at
nyseg.com.
Please return bottom portion with your payment. Make checks payable to NYSEG.
Account Number
NYSEG
12345678912
Late Fee After
01/20/22
NYSEG
P.O. BOX 847812
Due Upon Receipt
BOSTON, MA 02284-7812
$385.63
Amount Paid
$
SUSMITHA DOE
123 MAIN ST
AVERILL PARK NY 12018
Please do not write below this line.
601004107613300000385630000038563
"
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