Fuel Cost Adjustments Order

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INSERT ACCOUNT NUMBER HERE

CHECK HERE IF RENT CONTROL INFO ON FILE

NAME, ADDRESS & PHONE # OF FUEL COMPANY

SIZE OF OIL TANK (# OF GALLONS)

QUANTITY OF FUEL DELIVERED FOR YEAR ENDING 12/31/99

TOTAL # OF ROOMS IN BUILDING

FOR FUEL OTHER THAN OIL, SEE INSTRUCTIONS BELOW

RENT ROLL AS OF

(INSERT INFO FOR RENT CONTROLLED APTS. ONLY)

WHENEVER POSSIBLE, PLEASE FAX A COPY OF LAST YEAR'S FCA TO US AT (718) 789-8193

FOR GAS, INTERRUPTIBLE GAS OR OTHER FUELS, PLEASE FAX A COPY OF THE ANNUAL SUMMARY FROM YOUR FUEL PROVIDER SHOWING AMOUNT OF FUEL DELIVERED FOR CALENDAR YEAR 1999

CLICK HERE TO SUBMIT FORM