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Blank Utility Bill Form

The Utility Bill form is a document used to verify the payment of utility services, such as electricity, water, and gas. This form serves as proof of residency and can be required for various applications, including rental agreements and government assistance programs. To ensure a smooth process, consider filling out the form by clicking the button below.

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Table of Contents

The Utility Bill form serves as a crucial document for individuals and businesses alike, providing a clear record of utility services consumed over a specific period. This form typically includes essential information such as the account holder's name, service address, billing period, and the total amount due. It may also detail the breakdown of charges for various services, including electricity, water, gas, and other utilities, allowing users to understand their consumption patterns and costs. Additionally, the form often features payment options, deadlines, and contact information for customer service, ensuring that recipients have all the necessary resources at their fingertips. By maintaining accurate records through the Utility Bill form, consumers can manage their expenses more effectively and address any discrepancies that may arise with utility providers.

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Dos and Don'ts

When filling out the Utility Bill form, it’s essential to ensure accuracy and completeness. Here’s a list of things to do and avoid:

Do double-check all personal information for accuracy.
Do provide a current address where you receive your utility services.
Do include your account number if applicable.
Do use clear and legible handwriting or type your responses.
Do read all instructions carefully before starting.
Don't leave any required fields blank.
Don't submit the form without reviewing it for errors.

Completing the Utility Bill form accurately will help ensure timely processing. Take your time and follow these guidelines closely.

Utility Bill Sample

ENERGY STATEMENT	Account No:	1234567890-1
ENERGY STATEMENT	Statement Date:	09/07/2019
www.pge.com/MyEnergy	Due Date:	09/28/2019
www.pge.com/MyEnergy

Service For:

SPARKY JOULE 12345 ENERG'( CT

Questions about your bill?

Monday-Friday 7 a.m.-9 p.m. Saturday 8 a.m.-6 p.m. Phone: 1-800-743-5000 www.pge.com/MyEnergy

Ways To Pay

www.pge.com/waystopay

Your Account Summary

Amount Due on Previous Statement	$91.57
Payment(s) Received Since Last Statement	-91.57
Previous Unpaid Balance	$0.00
Current PG&E Electric Delivery Charges	$55.66
Silicon Valley Clean Energy Electric Generation Charges	$32.48
I Total Amount Due by 08/28/2019	$88.14

Monthly Billing History								Daily Usage Comparison
$200								1 Year	Last	Current
$200								Ago	Period	Period
$150								12.50	12.16	12.67
$100								■ ■ ■
$50								Electric kWh / Day
$50
$0	-+-----'-r-"-------	"'r�---	'-r"-----'-r-"	-----'-r�---	'-r"-----'-r"----'-r�---		'--r"------'-r"------i	0.12	0.16	0.17
2018 8/07		9/06 10/04 11/06 12/06 1/08 2/06			3/07 4/08	5/09 6/06	7/10 8/07 2019-�c____<=----			=::,__---l
			■	Electric	D	Gas		Gas Therms/ Day

Visit www.pge.com/MyEnergy for a detailed bill comparison

Important Messages

The Family Electric Rate Assistance (FERA) Program provides a monthly discount on electric bills for income-qualified households of three or more persons. To see if you qualify, please call 1-800-PGE-5000 or apply online at www.pge.com/fera.

El Programa FERA ofrece ahorros mensuales solo en las facturas de electricidad a hogares de ingresos econ6micos bajos y medianos con tres o mas personas. Para determinar si califica, por favor llame al 1-800-PGE-5000 o puede aplicar a traves de nuestra pagina web www.pge.com/fera.

Continued on page 6

Please return this portion with your payment. No staples or paper clips. Do not fold. Thank you.

Account Number:	Due Date:	Total Amount Due:	Amount Enclosed:
123456789-1	09/28/2019	$88.14
			$

PG&E

BOX 997300

SACRAMENTO, CA 95899-7300

Page 1 of 6

ENERGY STATEMENT	Account No:	1234567890-1
ENERGY STATEMENT	Statement Date:	09/07/2019
www.pge.com/MyEnergy	Due Date:	09/28/2019
www.pge.com/MyEnergy

Important Phone Numbers - Monday-Friday 7 a.m.-9 p.m., Saturday 8 a.m.-6 p.m. Customer Service (All Languages; Relay Calls Accepted) 1-800-743-5000

TTY 7-1-1

Servicio al Cliente en Espanol (Spanish) -��.P�IHf (Chinese)

1-800-660-6789	Djch VI) khach tieng Vi�t (Vietnamese)	1-800-298-8438
1-800-893-9555	Business Customer Service	1-800-468-4743

Rules and rates

You may be eligible for a lower rate. To learn more about optional rates or view a complete list of rules and rates, visit www.pge.com or call 1-800-743-5000.

If you believe there is an error on your bill, please call 1-800-743-5000 to speak with a representative. If you are not satisfied with our response, contact the California Public Utilities Commission (CPUC), Consumer Affairs Branch (CAB), 505 Van Ness Avenue, Room 2003, San Francisco, CA 94102, 1-800-649-7570 or 7-1-1 (8:30 AM to 4:30 PM, Monday through Friday) or by visiting www.cpuc.ca.gov/complaints/.

To avoid having service turned off while you wait for the outcome of a complaint to the CPUC specifically regarding the accuracy of your bill, please contact CAB for assistance. If your case meets the eligibility criteria, CAB will provide you with instructions on how to mail a check or money order to be impounded pending resolution of your case. You must continue to pay your current charges while your complaint is under review to keep your service turned on.

If you are not able to pay your bill, call PG&E to discuss how we can help. You may qualify for reduced rates under PG&E's CARE program or other special programs and agencies may be available to assist you. You may qualify for PG&E's Energy Savings Assistance Program which is an energy efficiency program for income-qualified residential customers.

Important definitions

Rotating outage blocks are subject to change without advance notice due to operational conditions.

Tier 1/Baseline allowance: Some residential rates are given a Tier 1/Baseline allowance - a CPUC approved percentage of average customer usage during summer and winter months. Your Tier 1/Baseline allowance provides for basic needs at an affordable price and encourages conservation. Your allowance is assigned based on the climate where you live, the season and your heat source. As you use more energy, you pay more for usage. Any usage over your baseline allowance will be charged at a higher price.

High Usage: An increased price per kWh whenever electricity usage exceeds four times the Baseline Allowance (Tier 1) in a billing period. This charge does not apply to Time-of-Use rate plans.

DWR bond charge: Recovers the cost of bonds issued by the Department of Water Resources (DWR) to purchase power to serve electric customers during the California energy crisis. DWR bond charges are collected on behalf of DWR and do not belong to PG&E.

Power Charge Indifference Adjustment (PCIA): Ensures that non-exempt customers under PG&E's GT and ECR rate schedules or who purchase electricity (generation) from non-PG&E suppliers pay their share of generation costs.

Gas Public Purpose Program (PPP) Surcharge. Used to fund state-mandated gas assistance programs for low-income customers, energy efficiency programs, and public-interest research and development.

Visit www.pge.com/billexplanation for more definitions. To view most recent bill inserts including legal or mandated notices, visit www.pge.com/billinserts.

Your Electric Charges Breakdown

Conservation Incentive	-$9.50
Transmission	12.42
Distribution	35.08
Electric Public Purpose Programs	4.71
Nuclear Decommissioning	0.33
DWR Bond Charge	1.91
Competition Transition Charges (CTC)	0.42
Energy Cost Recovery Amount	-0.22
PCIA	10.26
Taxes and Other	0.25
Total Electric Charges	$55.66

Update My Information (English Only)

Please allow 1-2 billing cycles for changes to take effect

Account Number: 1234567890-1

Change my mailing address to: ________________

City _____________ State		ZIP code ____
Primary	Primary

Phone#--------- Email --------------

Ways To Pay

•Online via web or mobile at www.pge.com/waystopay

•By mail: Send your payment along with this payment stub in the envelope provided.

•By debit card, Visa, MasterCard, American Express, or Discover: Call

877-704-8470 at any time. (Our independent service provider charges a fee per transaction.)

•At a PG&E payment center or local office: To find a payment center or local office near you, please visit www.pge.com or call 800-743-5000. Please bring a copy of your bill with you.

Page 2 of 6

ENERGY STATEMENT

Details of PG&E Electric Delivery Charges

Service For: 12345 ENERGY CT

Service Agreement ID: 111111111

Rate Schedule: E1 X Residential Service

07/02/2019 - 07/31/2019 Your Tier Usagel�-1��-2�

Tier 1 Allowance	297.00	kWh	(30 days x 9.9 kWh/day)
Tier 1 Usage	297.000000	kWh	@$0.22376	$66.46
Tier 2 Usage	83.000000	kWh	@$0.28159	23.37
Generation Credit				-44.68
Power Charge Indifference Adjustment				10.26
Franchise Fee Surcharge				0.25
Total PG&E Electric Delivery Charges				$55.66

Electric Usage This Period: 380.000000 kWh, 30 billing days
30kWh						----- =	Average Daily Usage 12.67 I
24
18
12	---------		------------�•--·--- - ------					----	--	- -
6
0	--+------"P.__.,.___.,._.,.__.,.___.,._.,.__.,.___.,._.,.__.,.__.,._.,.__.,.__.,._.,._.,.__.,._.,._.,.__.,._.,._.,.__.,._.,._.,.__.,._.,._.,.____.,.___,
	7/2	7/5	7/8	7/11	7/14	7/17	7/20	7/23	7/26	7/29

Due Date:	09/28/2019
Service Information	1111111111
Meter#	1111111111
Current Meter Reading	37,710
Prior Meter Reading	37,330
Total Usage	380.000000 kWh
Baseline Territory	X
Heat Source	B - Not Electric
Serial	G
Rotating Outage Block	50

Visit www.pge.com/MyEnergy for a detailed bill comparison.	Page 3 of 6

ENERGY STATEMENT

www.pge.com/MyEnergy

Details of Silicon Valley Clean Energy Electric Generation Charges

08/02/2019 - 08/31/2019 (30 billing days)

Service For: 12345 ENERGY CT

Service Agreement ID: 11111111

07/02/2019 - 07/31/2019

Rate Schedule:	E-1	$32.37
Generation - Total	380.000000 kWh @$0.08519
	Net Charges 32.37	0. 11
Energy Commission Surcharge
Customers receive clean electricity and save money with SVCE. Please see updated
SVCE electric rates and comparisons to PG&E at www.svcleanenergy.com/rates
Total Silicon Valley Clean Energy		$32.48
Electric Generation Charges

Account No:	1234567890-1
Statement Date:	09/07/2019
Due Date:	09/28/2019
Service Information
Total Usage	380.000000 kWh

For questions regarding charges on this page, please contact:

SILICON VALLEY CLEAN ENERGY 1-844-474-7823 customerservice@SVCleanEnergy.org

Additional Messages

About Silicon Valley Clean Energy (SVCE) Serving 13 Santa Clara County communities, SVCE is a locally-controlled, public agency providing residents and businesses with electricity from renewable and hydroelectric sources.

Understanding SVCE Charges

PG&E continues to provide and bill for electric delivery. SVCE replaces PG&E generation charges. Under PG&E Electric Delivery Charges, note the Generation Credit. This is what PG&E would have charged for power, and now credits back to you. The Power Charge Indifference Adjustment and Franchise Fee are factored into SVCE rates. Learn more:

https://www.svcleanenergy.orgies/your-bi11/.

SVCE is committed to protecting customer privacy.

Learn about our privacy policy at www.svcleanenergy.org/customer-confidenti ality

Visit www.pge.com/MyEnergy for a detailed bill comparison.	Page 4 of 6

ENERGY STATEMENT

www.pge.com/MyEnergy

Details of Gas Charges

08/02/2019 - 08/31/2019 (30 billing days)

Service For: 12345 ENERGY CT

Service Agreement ID: 1111111111

Rate Schedule: G1 X Residential Service

07/02/2019 - 07/31/2019	Your Tier Usagel�-1��-2�

Tier 1 Allowance	17.70 Therms (30 days x	0.59 Therms/day)

Tier 1 Usage	5.000000Therms @$ 1.28395	$6.42
Gas PPP Surcharge ($0.09047 /Therm)		0.45
Total Gas Charges		$6.87

Account No: 1234567890-1

Statement Date: 09/07/2019

Due Date: 09/28/2019

Service Information

Meter#	11111111
Current Meter Reading	2,588
Prior Meter Reading	2,583
Difference	5
Multiplier	1.031647
Total Usage	5.000000 Therms
Baseline Territory	X
Serial	G

Gas Procurement Costs ($/Therm)

07/02/2019 - 07/31/2019$0.28462

Gas Usage This Period: 5.000000 Therms, 30 billing days

Therms						= Average Daily Usage 0. 17 I
5						= Average Daily Usage 0. 17 I
5
4
3
2
7/2	7/5	7/8	7/11	7/14	7/17	7/20	7/23	7/26	7/29

Visit www.pge.com/MyEnergy for a detailed bill comparison.	Page 5 of 6

ENERGY STATEMENT	Statement Date:		09/07/2019
	Account No:	1234567890-1
www.pge.com/MyEnergy	Due Date:		09/28/2019
	Due Date:		09/28/2019

Important Messages (continued from page 1)

CARE Program. You may qualify for a monthly discount with the California Alternate Rates for Energy (CARE) Program. To find out more and apply online, visit www.pge.com/care.

Usted podría reunir los requisitos de un descuento mensual con el California Alternate Rates for Energy Program (CARE). Para obtener más información y hacer su solicitud en Internet, visite www.pge.com/espanol/care.

Electric power line safety PG&E cares about your safety. Be aware of your surroundings and keep yourself, tools, equipment and antennas at least 10 feet away from overhead power lines. If you see an electric power line fall to the ground, keep yourself and others away. Call 9-1-1.

Call 811 before you dig. A common cause of pipeline accidents is damage from digging. If you plan on doing any digging, such as planting a tree or installing a fence, please call 811 at least two working days before you dig. One free call will notify underground utilities to mark the location of underground lines, helping you to plan a safe project.

Visit www.pge.com/MyEnergy for a detailed bill comparison.

Page 6 of 6

Listed Questions and Answers

What is the Utility Bill form?
The Utility Bill form is a document used to verify a person's address or residency by providing proof of utility services. This form typically includes details such as the name of the account holder, the service address, and the billing period.
Why do I need to submit a Utility Bill form?
Submitting a Utility Bill form is often required for various applications, such as opening a bank account, applying for government assistance, or enrolling in school. It helps confirm your current address and ensures that you receive important correspondence.
What information is required on the Utility Bill form?
The form generally requires the following information:
- Your full name
- Your current address
- The name of the utility provider
- The account number
- The billing period
- The total amount due
How recent does the Utility Bill need to be?
Most organizations require the Utility Bill to be dated within the last 30 to 90 days. This timeframe helps ensure that the information is current and accurately reflects your residency.
Can I use a digital copy of my Utility Bill?
Yes, many organizations accept digital copies of Utility Bills. However, it's important to ensure that the document is clear and legible. Some may require a printed version, so it's best to check the specific requirements of the entity requesting the form.
What if my name is not on the Utility Bill?
If your name does not appear on the Utility Bill, you may still be able to provide proof of residency. Options include submitting a bill with your name and address or providing additional documentation, such as a lease agreement or a notarized letter from the account holder stating that you reside at the address.
Where do I submit the Utility Bill form?
The submission process varies depending on the organization requesting the form. Some may allow you to submit it online, while others might require you to mail or deliver it in person. Always follow the instructions provided by the requesting entity.
What should I do if I have questions about the Utility Bill form?
If you have questions or need assistance, it's best to contact the organization that requires the form. They can provide specific guidance and clarify any uncertainties you may have regarding the submission process or required information.

Form Overview

Fact Name	Description
Purpose	The Utility Bill form is used to document and verify utility expenses for various purposes, such as applying for financial assistance or proving residency.
Common Utilities	This form typically includes information about electricity, water, gas, and internet services.
Required Information	Users must provide details such as account numbers, billing periods, and total amounts due.
State-Specific Regulations	In many states, utility bill documentation is governed by local laws regarding financial assistance programs. For instance, California's Welfare and Institutions Code may apply.
Submission Methods	Utility Bill forms can often be submitted online, via mail, or in person, depending on the requirements of the receiving organization.