If you are experiencing a medical or other crisis and require extra time to make a payment or arrange a payment plan then please print this form and begin the process.

You will need to complete the top portion of the Medical Condition Certification and then have your doctor, public health official, Social Service official or Police/Sheriff complete the bottom portion. The completed form will need to be reviewed at Marshfield Utilities for compliance and approval. Please make sure the form is COMPLETE before submitting.

IMPORTANT – an approved MCC will give you a 21 day period to avoid the disconnection and prepare to make the needed payment or payment arrangement. This 21 day extension is valid only ONCE each year.

Download PDF Version

Please complete this form and return it to us by fax or email.

The MCC should be used ONLY if there is a need to provide continuous electric utility service because of a medical emergency or a protective service emergency. Also understand that acts of nature, equipment failure, etc. do happen and could result in an unplanned interruption of utility service and you are responsible for an emergency backup plan.