3. Third Party Notification Request.
(To be completed and signed by customer}
request that the Company send to the person
designated below notification of all past-due bills
forthe account, notices of termination of service and
notices of a right to a hearing atthe Mass: Dept. of
Telecommunications and Cable: I acknowledge that the
designated third party does not incur any Liability for
the payment of my account. I agree that the Company
incurs no liability whatsoever for failure to provide the
requested notice for any reason.
Name of Person or Agency to be Notified.(Please Print) '

Street Address

~
State_Zip

City
Customer Signature

Furthermore,such customers may designate a third
party of their own choice ~o whom the Company will also
send notices of past-due bills. Sending discontinuance
of service notices to a third party does not place
an obligation on that part~~ to pay the bill, nQr will it
necessarily defer or prevent the disconnection of
service if paymenf is not made as required. A customer
may voluntarily request the protection afforded by

'
~

Telephone Number(~)
~
of Third Party

Ve~izon developed procedures.in 1978, in
accordance with the Massachusetts Department of
Telecommunications and Cable(DEC)regulations, which
provide special pro"tectio~ to households in which all
residents are 65 years of age or older: These procedures
~ provide thatthe Company may not discontinue service
to those properly identified households without written
approval ofthe DTC.

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(continued)

•

NE427073MA -S K,

Y

1~

NE427013MA-S.K

 these~procedures by completing and signingfhis form
and returning into Ver.izon. Please mai(signed form
separately - da not send with your payment.The business
office also has a supply of these forms.
The protections afforded bythese procedures will
remain in effect until withdrawn by the customer or.
service is removed for reasons other than nonpayment.
Therefore, if youhave previously notified us and there
ts no change in the status'of your account relative to ~
'
these procedures, it is not necessary to return this form.
Please enclose the completed form in a sealed,stamped
envelope and mail if to:

Verizon
Attention: Eider Protection Form Processing
P.O. Sox 4845
Trenton, NJ 08650-4846

Age 65 Or Over Notification and Third Party Designation
1. Age 65 Or Over Notification (To be competed and
signed by customer)
hereby certify that I am the customer of record for the
account specified below, and that 1 and a(I other adult
residents of my household are 65 years of age or older,
and that alI the information given below is true and
correct:
(Please Print)
M y Name
Date of Birth
Street Address
City

State_Zi~

'

Customer Signature
'
Telephone Number(_ )
2.Other Adult Residents(Please Print)
Name
Date of Birth
Name
Date of Birth

(continued)

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