Appendix A-4.  

The ____ (UTILITY) INTENDS TO SHUT OFF THE (ELECTRICITY/GAS) TO THIS BUILDING TEN DAYS FROM THE DATE OF THIS NOTICE BECAUSE THE LANDLORD HAS NOT PAID HIS BILL.

IF SERVICE IS SHUT OFF, THIS BUILDING WILL NOT BE HEATED.

IF YOU OR ANOTHER PERSON WHO LIVES HERE IS VERY SICK OR HAS ANOTHER SERIOUS HEALTH PROBLEM, CALL THE NEW YORK CITY HEATLINE AT ____ (TEL. NO.) AND REPORT THE CONDITION. GAS OR ELECTRICITY WILL NOT BE SHUT OFF DURING THE COLD WEATHER PERIOD (NOVEMBER 1 - APRIL 15) IF YOU OR ANOTHER RESIDENT IS VERY ILL OR WILL HAVE A SERIOUS HEALTH PROBLEM IF THERE IS NO HEAT. A CASE WORKER FROM THE CITY'S HUMAN RESOURCES ADMINISTRATION WILL VISIT YOU OR THE OTHER PERSON TO VERIFY THE SERIOUS ILLNESS OR HEALTH PROBLEM. IF YOU HAVE ANY QUESTION REGARDING THEIR FINDINGS, YOU CAN ASK THE PUBLIC SERVICE COMMISSION FOR HELP BY CALLING 1-800-342-3377.