Required fields are marked with asterisks (*)

Cold Weather Protection Application

If you cannot pay your bill in full and need cold weather protection, fill out this form and return it immediately with your bill
or visit the RPU Service Center at 4000 East River Road NE, Rochester, MN 55906-2813.

Customer Name

Account Number from RPU Bill

Service Address

City

Zip Code

Contact Phone Number

Email Address

Total Amount you Owe

Total # of Persons in Household

Total Annual Household Income

Sources of Income (check all that apply for your household):

Employment

AFDC/GA

I do not pay for any of my own medical expenses.

I have attached all support materials – Section C, #3.

Other (please describe)

Please indicate if any of the following exists in your home (check all that apply):

Medical Emergency

Disabled Person in Residence

PAYMENT ARRANGEMENT: I agree to the following payment arrangement and will bring my total account balance current by April 30:

Payment Amount

By Date:

Payment Amount

By Date:

Payment Amount

By Date:

Payment Amount

By Date:

Payment Amount

By Date:

Payment Amount

By Date:

By typing my first and last names below, I am signing this document and I declare the above information is true and correct. I give my permission to any energy provider or public assistance agency that serves me to exchange income and billing information with other energy providers or public assistance agencies that serve my utility for the purpose of program qualification. I understand failure to comply with the payment arrangement may result in disconnection.

Customer Signature

Date