Deceased Account Handling Application Form - MA Gas

* 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:

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 service

Requesting that Gas Service be Placed Into the Name of the ESTATE of the Account Holder

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.

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 of the documents listed below:

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

2). 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.

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Massachusetts

New York

Deceased Account Handling Application Form - MA Gas