Deceased Account Handling Application Form

* indicates required fields

Please complete the following information regarding the Deceased Account Holder:

Deceased Customer Name:

Service Address:

Account Number (Please enter a valid value in the format of 12345-12345):

Date Deceased (MM/DD/YYYY):

Please complete the following information regarding yourself:

Contact Name:

Full Address:

Email Address:

Phone Number (Please enter a valid value in the format of 999-999-9999):

Relationship to the deceased account holder:

Please check the applicable option below and follow the instructions depending on what action you are requesting. Submit this completed form along with the required documents. Requests will not be processed until all required documents are received. Partial documentation will not be sufficient to complete the necessary action requested.

Application Options:

Requesting to Close the account and turn off serviceRequesting that Gas Service be Placed Into the Name of the ESTATE of the Account HolderProvide Proof of Active Probate Process

Close the account and turn off service

NOTE: By requesting this option, you attest that you have authorization to make this request and disconnecting the gas service will not adversely impact another person who may be benefiting from the service.

1) Please Attach Photo Proof for the following item. (Note: Photo images will be accepted).

A copy of the Death Certificate of the account holder.

2) In addition, please provide a Name and Address to where the Final Bill should be sent.

(Final Bill) Full Name:

(Final Bill) Full Address

123 East Main St, Anytown, NY 12345

IMPORTANT! - Please be aware a DISCONNECT request cannot be issued until a copy of the Death Certificate is received.

New Mailing Address?

Is There a New Mailing Address?

YesNo

Please enter customer's Full Name and the new FULL Mailing Address.

Full Name:

New Full Mailing Address

123 East Main St, Anytown, NY 12345

Gas Service Be Placed In The Name of The Estate

Would you like to?

Update the account to an Estate and leave the gas service on ORUpdate the account to an Estate, close the account and send final bill

Please send in completed copies for each of the documents listed below:

1). A copy of the Death Certificate of the Account Holder.

2). Attach Copy of Deed or Lease Under Deceased Name

3). Attach Copy of Executor’s ID

4). Send in ONE of the following, including a Court Seal (select one);

Executor or Administrator Certificate	Letters of Administration
Letters Testamentary	Voluntary Administrator's Affidavit
Letters of Authority for Personal Representative to the Estate

Attach Executor or Administrator Certificate

Attach Letters Testamentary

Attach Letters of Administration

Attach Administrator's Affidavit

Attach Letters of Authority for Personal Representative to the Estate

Please provide a Name and Address to where the Final Bill should be sent.

(Final Bill) Full Name:

(Final Bill) Full Address

123 East Main St, Anytown, NY 12345

NOTE! - Powers of Attorney and Last Will and Testaments are NOT sufficient documentation when the account holder is deceased.

Remove Account From Direct Pay/EFT

Would you like to Remove the Account from Direct Pay/EFT

Yes - Remove the account from Direct Pay/EFTNo - Keep the account enrolled in Direct Pay/EFT

NOTE: Depending on the date of the scheduled withdrawal or if the funds are in “pending” status, we cannot guarantee that the funds will not be withdrawn.

New Mailing Address?

IMPORTANT NOTICE! If there will be a new Mailing Address associated with the account, please send the full name and full mailing address at the time the estate documents are sent in. Until then, we will continue to send monthly bills to the current mailing address.

Provide Proof of Active Probate Process

If Estate is currently in the probate process and no Executor/Administrator documents have been sent, please submit the documentation below. Once received, a temporary hold of 180 days will be placed on the account in order to postpone any disconnection.

1). A copy of the Death Certificate of the Account Holder.

2). A copy of the Filing Receipt from Probate Court showing that filing fees have been paid and case has been opened.

Submit court case number if one has been given:

3. Submit a valid email address for follow up:

Important: You will receive a follow up email requesting additional documentation within a few days. Once the Estate has been created and letters of administration or executorship have been given, please submit estate documentation as well as a copy of the ID of the executor or administrator using that follow up email.

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Massachusetts

New York

Deceased Account Handling Application Form - NYC