PLEASE PROVIDE YOUR MASTER ACCOUNT AND FACILITY ID TO EXPEDITE THE PROCESS.
MASTER ACCOUNT FACILITY I.D.
CUSTOMER NAME (FIRST AND LAST AS IT APPEARS ON YOUR BILL)
ADDRESS SPACE #
CITY PRIMARY PHONE
20% DISCOUNT CARE APPLICATION
PLEASE USE DARK BLUE OR BLACK INK ONLY.
Please complete and return this application by mail or fax.
Mail to: SoCalGas M.L. GT19A1, P.O. Box 3249 Los Angeles, CA 90051-1249 or Fax to: (213) 244-4665
/ /
2
3
Total number of persons in your household (include yourself, other adults, and children):
1 2 3 4 5 6 If more than 6:
Are you (or someone in your household) enrolled in any of the following assistance programs?
YES (If yes, please fill in the circle(s)
l
)
Please mark your sources of income
Social Security
SSP or SSDI
Pensions
Interest or dividends from savings, stocks, bonds,
or retirement accounts
Wages and/or salary
Unemployment benefits
Insurance or legal settlements
Disability or workers compensation payments
Spousal or child support
Scholarships, grants, or other aid used
for living expenses
Rental or royalty income
Cash, other income, or profit from self-employment
Medi-Cal/Medicaid: Under age 65
Medi-Cal/Medicaid: 65 or older
Medi-Cal for Families A&B
Women, Infants and Children Program (WIC)
CalWORKs (TANF) or Tribal TANF
Head Start Income Eligible - Tribal Only
Bureau of Indian Affairs General Assistance
CalFresh (Food Stamps)
National School Lunch Program (NSLP)
Low Income Home Energy Assistance Program (LIHEAP)
Supplemental Security Income
Declaration Please read and sign below.
I state that the information I have provided in this application is true and correct. I agree to provide proof of CARE eligibility if asked. I agree to
inform Southern California Gas Company (SoCalGas
®
) within 30 days if I no longer qualify to receive a discount. I understand that if I receive the
discount without qualifying for it, I am required to pay back the discount I received. I understand that SoCalGas can share my information with
other utilities or agents to enroll me in their assistance programs.
SIGNATURE: DATE:
X
N20E0090A 0320 Source Code: 9B
Form 6677 EN Meter: Submetered
- -
© 2020 Southern California Gas Company. Trademarks are property of their respective owners. All rights reserved.
The CARE program is funded by California utility customers and administered by Southern California Gas Company under the auspices of
the California Public Utilities Commission. Program funds will be allocated on a first-come, first-served basis until such funds are no longer
available. This program may be modified or terminated without prior notice.
$0 - $34,480
$34,481 - $43,440
$43,441 - $52,400
$52,401 - $61,360
$61,361 - $70,320
If more than $70,320, enter the dollar amount here
$ , .00 per year.
NO (If no, what is your yearly household
income before deductions, including all
members of the household?)
1
