U S G Pipeline Company

ORIGINAL VOLUME NO. 1

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Effective Date: 01/19/2009, Docket: RP09-177-000, Status: Effective

First Revised Sheet No. 93 First Revised Sheet No. 93

Superseding: Original Sheet No. 93

SERVICE REQUEST FORM

Robert B. Cooper

USG Pipeline Company

550 West Adams Street

Dept. # 143-61

Chicago, IL 60661-3676

Re: ____ New Service ____ Rate Schedule FT

____ Modification of service

under Agreement No. ____ ____ Rate Schedule IT

___________________________ (Shipper) hereby requests service as specified above

from USG Pipeline Company (Transporter) and concurrently provides the following

information in connection with this request:

1. Complete legal name of Shipper:

____________________________________________________________________

____________________________________________________________________

2. Type of legal entity and state of incorporation:

____________________________________________________________________

____________________________________________________________________

3. Type of company:

_________________ Local Distribution Company

_________________ Intrastate Pipeline

_________________ Interstate Pipeline

_________________ Producer

_________________ End-User

_________________ Marketer

_________________ Broker

_________________ Other (fill in)