STATE OF NEW YORK
DEPARTMENT OF PUBLIC SERVICE
THREE EMPIRE STATE PLAZA, ALBANY, NY 12223
Please E-mail to: secretary@dps.ny.gov
- or - Fax to:(518) 474-9842

BILLING INFORMATION FORM
(Pease clearly print or type all information below)

Name and Title of Authorized Representative ______________________________________________________________________
Name of Business/Requester ___________________________________________________________________________________
Address   ___________________________________________________________________________________
                                                                                                  (street) (city) (state) (zip)
Contact Information ___________________________________________________________________________
(phone) (fax) (email)
Business I.D. No. ______________________________________________________________________________
Business' Reference or Purchase Order No. ________________________________________________________
Delivery Account Name and No. __________________________________________________________________
By submitting this form, I hereby agree to pay fees associated with the following request.

Detailed description of requested material:   (please be specific)

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________ Number of pages requested (if known)_______

Fees
According to 16 NYCRR §6-1.2, unless otherwise prescribed by statute, photocopies of official documents (public records) will be furnished in accordance with the following pricing schedule:

(a) The fee for duplication of Commission records from originals 8-1/2" x 11" and   8-1/2" x 15"   shall   be   25 cents per page.
(b) The fee for special reproductions such as photocopies of large items, copies of   microfilmed records, etc., shall be based upon the average unit cost for copying  a record, excluding fixed costs   of the Department, such as operator salaries and  overhead.
(c) The fee for duplication of commission records onto a CD shall be $4 per CD.

Copying fees are not charged to: (1) Federal agencies, New York State agencies (including authorities) or local agencies in New York; (2) other state's Public Service Commissions or Public Utility Commissions; (3) Consumers, or their designated representatives, for a single copy of their case files; or (4) Requesters, where the records sought in any month total fewer than 20 pages; this 20 page limit applies to requests of the same person, or firm, within any 30-day period.

State Finance Law
Section 18 (4) of the State Finance Law authorizes charging interest on the outstanding balance of debt and a  $10 late fee (on invoices 60 days past due). Subdivision 5 of that section authorizes a collection fee that may not exceed 22 percent (on invoices 90 days past due). Section 19 of the Finance Law authorizes a charge for returned checks.

INTERNAL AND FINANCE USE ONLY
(Office of General Counsel/Central Operations) (Finance and Budget)
Number of Pages Photocopied_______________________ Billing Date_______________________________________
Number of CDs Ordered____________________________ Invoice Number___________________________________
Date Filled_______________________________________ Bill Amount_______________________________________
Person taking request______________________________ Interest Amount____________________________________
Person filling order________________________________