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Please also forward a second copy of the dispute form to: - page 4 / 7

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SECTION IA – MINOR

In order to process your dispute for SECTION IA – MINOR you will be required to answer all questions in this section and send in the following documents:

  • A copy of a Police Report is required (page 5)

  • A copy of your Birth Certificate is required

  • If obtainable, a Statement of Responsibility can be sent in for this section (page 5)

    • 1.

      What is the address you are disputing? (house number, street, city, zip code)

___________________________________________________________________________________

2.

Did you ever live at the disputed address?

Yes F

No F

3.

Do you know who lived there during the disputed dates? Yes F

No F

If yes, who:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Relationship________________________

4.

Date of Birth: (Month/Day/Year) ______________________________________________

3 FINAL+BILL+DISPUTE+FORM+KEYSPAN+(3)[1].DOC

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