Section 512.APPENDIX A Uniform Disclosure Statement

UNIFORM DISCLOSURE STATEMENT

Name:

Business Address:

Internet Address:

Phone and hours of operation:

Rates and Product Information
Price (in cents/therm) and number of months this price stays in effect:
Utility Gas Supply Cost to compare (in cents/therm):	Price:	Effective:	Expires:

(Name of the alternative gas supplier) is not the same entity as your gas delivery company. You are not required to enroll with (name of alternative gas supplier). Beginning on (effective date), the utility gas supply cost rate per therm is (cost). The utility gas supply cost will expire on (expiration date). For more information go to the Illinois Commerce Commission’s free website at www.icc.illinois.gov/ags/consumereducation.aspx.
Other periodic charges:
Total Price (in cents/therm) with other periodic charges:	50 therms	100 therms	300 therms

Length of contract:
Price after the initial price:
Contract Renewal
Contract Renewal:
Right to Rescind and Terminate
Rescission:	You have the right to rescind (stop) your enrollment within 10 business days after the date on your Gas Utility’s written notice confirming the switch of your supplier. You may call us at (toll-free number) or your utility at (toll-free number) to rescind.
Termination:	You have the right to terminate an agreement with an alternative gas supplier AT ANY TIME WITH NO TERMINATION FEES AND NO PENALTIES. You may call us at (insert AGS’ toll-free number) to terminate this contract.

This is a sales solicitation and the seller is (insert AGS name), an alternative gas supplier. If you enter into a contract with the seller, (insert AGS name) will be your gas supplier. The seller is not endorsed by, representing, or acting on behalf of, a utility or a utility program, a consumer group or consumer group program, unless the AGS is, through the consumer group, offering services at prices, terms and conditions that are available solely to members of that organization, or a governmental body or program of a governmental body.

If you have any questions or concerns about this sales solicitation, you may contact the Illinois Commerce Commission's Consumer Services Division at 800-524-0795.

Date:

Agent name/ID: