20% DISCOUNT CARE APPLICATION
PLEASE USE DARK BLUE OR BLACK INK ONLY
ACCOUNT NUMBER
PLEASE PROVIDE YOUR ACCOUNT NUMBER TO EXPEDITE PROCESSING.
CUSTOMER NAME (FIRST AND LAST AS IT APPEARS ON YOUR BILL)
ADDRESS
APT/SPACE #
CITY PRIMARY PHONE
Please complete and return this application by mail, fax, or apply online at socalgas.com/CARE.
Mail to: SoCalGas M.L. GT19A1, P.O. Box 3249 Los Angeles, CA 90051-1249 or Fax to: (213) 244-4665
/ /
1
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:
$0 - $34,480
$34,481 - $43,440
$43,441 - $52,400
$52,401 - $61,360
$61,361 - $70,320
NO (If no, what is your yearly household income before
deductions, including all members of the household?)
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
)
If more than $70,320, enter the dollar amount here
$
, .00
per year.
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
- -
N20E0089A 0320 Source Code: 9B
Form 6491 EN Meter: Residential
© 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.
