THIRD PARTY DESIGNATION for CREDIT NOTICES
This Form Should Be Printed Out, Completed in Full, and Mailed to
Customer Account Services Division; Central Hudson
284 South Avenue; Poughkeepsie NY 12601
PLEASE PRINT
Customer’s Name __________________________________________________________________________
Central Hudson Account Number ______________________________________________________________
Address __________________________________________________________________________________
City/State/Zip Code _________________________________________________________________________
Customer’s Signature _______________________________________________________________________
Designated Third Party’s Name _______________________________________________________________
Address __________________________________________________________________________________
City/State/Zip Code _________________________________________________________________________
Third Party’s Signature ______________________________________________________________________
An occasion may arise when a customer is unable to respond to an important notice from Central
Hudson about the status of their service or account. For such instances, we offer a voluntary program
which will ensure that someone else – a willing “Third Party”– is informed of the situation. This program
is especially helpful to the ill, the elderly, or someone absent from home, in preventing unnecessary
disconnection of services.
A customer may choose a relative, friend, clergy person, community or social service agency to
receive future Third Party Notifications, who will then help ensure that the customer is made aware of
the situation.
The Third Party is in no way responsible for paying the bill or any part of it. Your signature and
the signature of the person or agency designated as your Third Party are both required.
click to sign
signature
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signature
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