Form Eia-457f - Household Natural Gas Usage Form Page 2
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1
21. 1.
Please provide information on natural gas sold and/or delivered to this housing unit from October 1, 2004, to
the present date.
Check the
Units Used to Measure
Circle the Letter
Circle the Letter
the Natural Gas and
that Indicates
that Indicates if the
Enter the
How the
Enter the
Natural Gas was Sold,
Quantity Used this Period
Quantity Used
Enter the
Date Meter
Delivered, or Both
Therms
was Determined
Total Dollar Amount
Was Read
S=Sold Only
Cubic feet (CF)
A=Actual
(including taxes and
(Month/Day/Year)
D=Delivered Only
Hundreds of CF (CCF)
E=Estimated
other charges) for
a
Billing
for each
B=Both Sold and
Thousands of CF (MCF)
R=Read by
this Billing Period
Period
Billing Period
Delivered
Other ________________
Customer
(US$ 000.)
(Specify)
1
S
D
B
A
E
R
2
S
D
B
A
E
R
3
S
D
B
A
E
R
4
S
D
B
A
E
R
5
S
D
B
A
E
R
6
S
D
B
A
E
R
7
S
D
B
A
E
R
8
S
D
B
A
E
R
9
S
D
B
A
E
R
10
S
D
B
A
E
R
11
S
D
B
A
E
R
12
S
D
B
A
E
R
13
S
D
B
A
E
R
14
S
D
B
A
E
R
15
S
D
B
A
E
R
16
S
D
B
A
E
R
a. Include in the Total Dollar Amount for this Billing Period all state and local taxes, fuel adjustment charges and system charges
(minimum bill or base charge). Exclude merchandise, repairs, and service charges. If the household is on the budget plan, do not provide the
.
budgeted bill; instead, provide the dollar amount that is the cost of the actual consumption in the period
Step 3
Please provide the following information for the
Use
the
enclosed
self-addressed
2.
person who completed this form. Please print.
envelope and return the completed form
to:
Name: ___________________________________
U.S. Department of Energy
Company: ________________________________
c/o The Contractor
Telephone: _______________________________
Contractor’s Street Address
Contractor’s City, State, and ZIP Code
E-mail Address: ___________________________
Fax Number: ______________________________
Or you may FAX the completed form to
The Contractor at NNN-NNN-NNNN
Date: ____________________________________
For Office Use Only:
Fuel
Unit
Beginning Date
Ending Date
R
Period s
F/L
9
10
11-16
17-22
23
30-31
35
2
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