AffidavitFoothills Communications Affidavit of Federal Government EmploymentThis affidavit is submitted to request temporary relief under the Temporary Utility Penalty and Service Disconnection Exemption Policy for federal government employees affected by the current federal government shutdown.Name(Required) First Name Middle Name(Required) Last Date of Birth(Required)Last 4 digits of SSN(Required)Foothills Communications Phone NumberFoothills Communications Account NumberEmail(Required) Enter Email Confirm Email RESIDENTIAL ADDRESS Must be a street address (not a P.O. Box) and your Foothills service residence.Street Address (911 Address)(Required)AptCity(Required)State(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code(Required) Affidavit StatementAffirmation1(Required) I agree(Required) I hereby affirm and attest to the following: 1. I am currently employed by the United States Federal Government and/or represent a federal agency. 2. My regular income has been suspended or reduced as a direct result of the ongoing federal government shutdown. 3. I am experiencing temporary financial hardship due to this lapse in income. 4. I am requesting relief in accordance with the utility’s temporary exemption policy, which may include: – Waiver of late payment penalties, – Exemption from phone, internet, television service disconnection, and – A flexible payment plan upon the resumption of government operations. 5. I understand that this exemption is temporary and agree to make arrangements to bring my account current once regular pay resumes.APPLICANT SIGNATURE By my electronic signature below, I certify that the information provided above is true and correct, and agree to the above Certifications. I further certify that I have read and understand the above Notices and Disclosures of this Enrollment Form.Name(Required) First Last Date(Required) MM slash DD slash YYYY CAPTCHAΔ
