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Financial Statement Calculator - Upstate New York

Please read the instructions and guidelines before proceeding with form submission for review. 

Required Documents - please check this list of acceptable documents for proof of income and expense.

* indicates required fields

Please note: This is NOT a Deferred Payment Agreement. This is a pre-screening to determine your eligibility. If you qualify, you will be contacted via your preferred method of communication.


Physician Information
If you want to renew the prior Medical Emergency Protection you have on your account, please complete the following:
Account Holder Information
Step 1 of 3 - Who resides in your household

(Age 18+)

(Age under 18)

Step 2 of 3 - What is your monthly household income?

Please note: Proof of Income is required for all types of income sources. If no income, proof is also required.

Supporting documentation will be required to be uploaded at the end of this application unless obtaining a copy of your Financial Statement for DSS.
  • Please provide the exact dollar amounts that appear on any income documentation.
  • Please check our glossary of Definitions if you need clarifications while completing this form.
Household Member 1 Household Member 2 Household Member 3 Household Member 4
Gross Salary
Multiply your weekly gross income by 4.333 or multiply bi-weekly by 2.166.Then enter dollar amount.
Does your pay fluctuate from pay period to pay period?
How often are you paid?
Public Assistance
Enter amount of any kind of cash assistance from DSS that covers rent or utility. E.g. Section 8
Social Security
Enter cash amount you get monthly for pension or survivor benefits.
SSI
Enter cash amount you get as support from Social Security based on income, age, sight and/or disability.
SSDI
Enter cash amount you get as support from Social Security based on earned work credits from previous employment.
Unemployment
Enter the cash amount you get because of loss of job.
Food Stamps
Enter the amount you get food purchase - SNAP.
Other Income 1
Enter the amount you get for spousal support, co-tenant, alimony, child support.
Other Income 2
Enter amount you get for pension, rental property, Section 8, veteran/military benefits, dividends, additional income from employed children.

* Proof of no income must be provided for each adult claiming no income (Department of Social Services Denial Letter, Notarized letter from source of rent/housing funding or family member who is paying living expenses, SNAP Denial/approval letter, Federal form 4506-T)
IMPORTANT: For your application to be processed, you will need to provide supporting documentation at the end of this application. Please check this list of acceptable documents.
Step 3 of 3 - What are your monthly household expenses?

Please note: Supporting documentation will be required to be uploaded at the end of this application unless obtaining a copy of your Financial Statement for DSS.

  • Please provide the exact dollar amounts that appear on any expense documentation.
    • Per NYS Guidelines, these are the allowable expenses that may be claimed to qualify for a Minimum Deferred Payment Agreement or Medical Emergency Renewal. Other expenses you may have will not be considered in calculating fair and equitable payment agreement terms.
  • Please check our glossary of Definitions if you need clarifications while completing this form
Amount
Monthly Rent or Mortgage
Enter the dollar amount you pay for rent or mortgage. IF subsidized, enter the amount that you pay.
Real Estate Tax
Divide your yearly property or school taxes by 12. Then enter dollar amount. DO NOT include anything IF tax is included in monthly mortgage.
Home Owners/Rent Insurance
Divide your yearly property or school taxes by 12. Then enter dollar amount. DO NOT include anything IF tax is included in monthly mortgage.
Average National Grid Bill
(Provided in email from National Grid)
Non-National Grid Utilities
Enter average amount you pay for other non-Nationalgrid utilities or company e.g. propane, kerosene, oil, wood pallets, NYSEG, RGE, National Fuel Gas etc.
Car Payment
Enter car note amount.
Car Insurance
Transportation
Enter amount you pay for essential transportation e.g. bus/taxi, parking for work, regular basic maintenance, gas.
Food/Nonfood
State maximum based on # of household members
Personal
State maximum based on # of household members
Medical Expenses
Enter out-of-pocket expense amount for prescription that is current. DO NOT include past due bills.
Basic Phone
State maximum based on # of household members
Child Care Expenses
Enter employment-related childcare. E.g. Child daycare so I can go to work.
Court Ordered Expenses
Must have court documentation. IF amount is automatically deducted from paycheck, do not include here.
Other Expenses
Enter dollar amount you spend on water & sewer, trash removal, laundry services & installment or rental payments for stove, refrigerator, washer or dryer.
Other Expenses Description
(Fill this out if an amount
is entered in "Other Expenses")
If you have entered a dollar amount in "Other Expense", please list all the items that you are claiming (e.g. trash removal, laundry service, rental payment for essential amenities, etc.) DO NOT include credit cards or loan payments, cable bills, pet expenses, etc.
Monthly Cash Flow



Instructions

Please note: This is NOT a Deferred Payment Agreement. This is a pre-screening to determine your eligibility. If you qualify, you will be contacted via your preferred method of communication.

Please enter a valid value in the format of 999-999-9999.
The Deferred Payment Agreement Form will be sent to the following Email:





Upload all required documents (pdf, doc, jpg, etc.)


Please check the list of acceptable documents for proof of income, proof of no income and expenses. 

Providing incorrect or insufficient proof documents will delay your application. Please do not upload the same document more than one time.

Instructions

Next Steps

Please call National Grid Credit & Collections at 1-800-443-1837 to discuss other Payment Agreement options.

Next Steps

Please call National Grid Credit & Collections at 1-800-443-1837 to discuss other Payment Agreement options. Your previously defaulted agreement may be able to be restored. In order to restore the agreement you will be required to pay a restoral amount (total amounts missed + current bill).

Next Steps

Visit the NY HEAP website for information that may apply to you. 
Website: https://otda.ny.gov/programs/heap

Visit the NY My Benefits website to find programs that may benefit you.
Website: https://mybenefits.ny.gov/mybenefits/begin

You can also find contact information of your local HEAP office. 
Website: https://otda.ny.gov/programs/heap/contacts

Next Steps

You can seek assistance from your local agencies e.g. Catholic Charities, Salvation Army, Department of Social Services. A local agency may offer you one-time financial assistance that can contribute to your overall outstanding balance or your restoral amount. 

If you would like assistance on programs and services that may be available to assist you, National Grid has Consumer Advocates who can help: ngrid.com/consumeradvocates.

Visit the NY My Benefits website to find programs that may benefit you.Website: https://mybenefits.ny.gov/mybenefits/begin

Instructions

Due to a positive monthly cash flow per the Financial Statement you just completed, you are ineligible for a Medical Emergency Renewal.

If you have a past due balance and need to make payment arrangements, please call National Grid Credit & Collections at 1-800-443-1837 to discuss payment options.

If you have any additional questions, please call National Grid Customer Service at 1-800-642-4272.

Please note that you also have the right to seek a review of National Grid’s determination from the New York State Public Service Commission online at https://dps.ny.gov/file-complaint, by phone at 1-800-342-3377 (toll free), 8:30 a.m.- 4 p.m. Monday-Friday, or by mail: New York State Public Service Commission, Empire State Plaza, Albany NY 12223. You may also contact the PSC Hotline at 1-800-342-3355 between 7:30 a.m.-7:30 p.m. Monday-Friday.

Instructions

Click Submit below and a copy of the financial statement will be emailed to: