FORM 998-A
Certification of Primary Care Provider
CITY OF MANTECA UTILITY BILLING
THIS SECTION TO BE FILLED OUT BY ACCOUNT HOLDER
_____________________________________ ___________________________________________ Account Number Service Address
_____________________________________ ___________________________________________ Account Holder Name Person Receiving Primary Care
_____________________________________ ___________________________________________ Date of Bill seeking Payment Arrangement Amount of Bill Seeking Payment Arrangement I, the account holder, certify under penalty of perjury that the above-named person receiving primary care resides at the service address.
_______________________________________ ____________________________________________ Account Holder Signature Phone Number
THIS SECTION TO BE FILLED OUT BY PRIMARY CARE PROVIDER
_____________________________________ _____________________________________________ Name of Primary Care Provider Name of Clinic or Medical Facility _____________________________________ ______________________________________________ Clinic Address Clinic Phone Number
_____________________________________ _______________________________________________ National Provider Identifier Person Receiving Primary Care I, the primary care provider, certify under penalty of perjury that I provide care to the above-name person and that discontinuation of water service to this person would pose a serious threat to his or her health safety.
_____________________________________
Primary Care Provider Signature
THIS SECTION TO BE FILLED OUT BY CITY STAFF
ATTACHMENT 3