Provides a 30 day disconnection delay for residential customers of PUCO-regulated electric, natural gas, and water utilities who are facing a disconnection for nonpayment in cases where disconnection would be hazardous to the health and safety of a permanent resident of the home. **Form must be completed by a licensed physician, physician assistant, clinical nurse specialist, certified nurse practitioner, certified nurse-midwife, or local board of health physician. *The form may be used no more than three times in a rolling 12-month period.