Please take a minute to complete this survey about your winter utility bills. Sharing your voice and your story helps us be more effective in pushing utility companies to be prepared—without rate increases for consumers—and can help reduce impacts of future power outages.

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* 1. Name:

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* 2. City:

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* 3. Zip Code:

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* 4. Who provides your electric?

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* 5. Highest Bill?

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* 6. What was your bill for the same month last year?

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* 7. Who provides your gas service?

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* 8. Highest Bill?

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* 9. What was your bill for the same month last year?

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* 10. How much of a problem is it for you to pay your January or February utility bill(s)?

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* 11. What do you have to cut back on to pay your January or February utility bill(s)?

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* 12. Can we sign your name to take these actions to stop skyrocketing bills?

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* 13. How could your utility provider be better prepared for serving consumers during the next storm?

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* 14. Signed Name/Signature

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* 15. Date

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