APPLICATION FOR ADMINISTRATIVE WARRANT DOCKET NO. AUTHORIZING UTILITY COMPANY TO ACCESS PREMISES G.L. c. 164, § 116 APPLICANT NAME & TITLE Massachusetts Trial Court District Court Department COURT DIVISION GAS OR ELECTRIC COMPANY NAME & ADDRESS COMPANY EMPLOYEE WHO WAS REFUSED ACCESS & DATE CUSTOMER NAME (& ADDRESS, IF DIFFERENT FROM PREMISES) ADDRESS OF PREMISES WHERE METER & RELATED ITEMS LOCATED AND TO WHICH ACCESS WAS REFUSED METER NO(s), IF RELEVANT TO ANY JUSTICE OR MAGISTRATE AUTHORIZED TO ISSUE CRIMINAL PROCESS: As authorized by the above-named gas or electric company, as such terms are defined in G.L. c. 164, § 1, and on its behalf, the above-named and undersigned applicant on oath complains that on the above-listed date the above-named officer or servant of such company who was duly authorized in writing by the president, treasurer, agent or secretary or municipal lighting plant manager of such company and who displayed on an outer garment a suitable photo identification badge issued by such company, was prevented or hindered from entering at a reasonable time the above-listed premises, which are supplied with gas or electricity by such company, for the purpose of examining or removing the meters, pipes, wires, fittings and works for supplying or regulating the supply of gas or electricity and of ascertaining the quantity of gas or electricity consumed or supplied, or was prevented or hindered from making such examination or removal. THEREFORE the undersigned applicant requests this Court to issue an administrative warrant pursuant to G.L. c. 164, § 116, commanding the sheriff or any of his or her deputies, or a constable of the town where such company is located, to take sufficient aid and accompany to such premises any duly authorized officer or servant of such company, who shall examine such meters, pipes, wires, fittings and works for supplying or regulating the supply of gas or electricity, and ascertain the quantity of gas or electricity consumed or supplied therein, and shall, if required and subject to the requirements of G.L. c. 164, §§ 124-124H, remove any meters, pipes, wires, fittings and works belonging to such company. 9 _____ pages of additional documentation are attached to this application and incorporated herein by reference. DATE SIGNED SIGNED UNDER THE PENALTIES OF PERJURY. x ________________________________________________ APPLICANT (11/09) American LegalNet, Inc. www.FormsWorkFlow.com