Kentucky West Virginia Gas Company

Third Revised Volume No. 1

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Effective Date: 07/01/1993, Docket: RS92- 18-002, Status: Effective

Original Sheet No. 85 Original Sheet No. 85 : Superseded

Service Request Form (continued)

(i) Points of Receipt

Maximum Name of Pipeline,

Location Daily Total for Gathering or Other Estimated

of the Receipt Term of Entity Delivering Is Supplier Entry Take-or-Pay

Receipt Gas Obligation Contract Gas into an affiliate Pressure Relief

Point Production (dth & MCF) (dth & MCF) Pipeline's System of Pipeline? (psig) (Yes/No)

Percentage of gas for which service is requested for which Pipeline will receive take-or-pay relief.

_____________________%