Fillable 20% DISCOUNT CARE APPLICATION The California Alternate Rates

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20% DISCOUNT CARE APPLICATION The California Alternate Rates

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20% DISCOUNT
CARE APPLICATION
The California Alternate Rates for Energy (CARE) program
offers eligible SoCalGas
®
customers a 20 percent discount on
their monthly natural gas bill. The discount will be applied to the
monthly natural gas bills following the date that the application is
approved by SoCalGas.
Please submit a completed application by using one of the
methods listed below:
1) Visit myaccount.socalgas.com or socalgas.com/care.
Your request will be processed instantly. (For customers who
have a SoCalGas bill account)
2) Call 866-716-3452 anytime 24 hours a day. Please have your
account number ready.
3) Return the completed and signed form by mail or fax to
213-244-4665.
PAGE 1 OF 7
PUBLIC ASSISTANCE PROGRAMS
If you or another person in your household receives benefits
from any of the following programs:
THERE ARE TWO WAYS TO QUALIFY
Medi-Cal/Medicaid
Medi-Cal for Families A & B
Women, Infants, & Children (WIC)
CalWORKs (TANF)
1
/ 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
1
Includes Welfare-to-Work
OR
For each additional household member, add $8,840
*Includes current household income from all sources before
deductions.
Number of Persons in Household Total Annual Income
*
MAXIMUM HOUSEHOLD INCOME
(effective June 1, 2019 to May 31, 2020)
PAGE 2 OF 7
$33,820
$42,660
$51,500
$60,340
$69,180
$78,020
$86,860
1-2
3
4
5
6
7
8
CONDITIONS FOR PARTICIPATION:
1) You must meet the qualification requirements in the
table above.
2) The natural gas bill must be in your name and the
address must be your primary address.
3) You must not be claimed as a dependent on another
person’s income tax return other than your spouse.
4) You must recertify your application when requested.
5) You must notify SoCalGas within 30 days if you no
longer qualify.
6) You may be asked to verify your eligibility for CARE.
PAGE 3 OF 7
OTHER PROGRAMS AND SERVICES YOU MAY QUALIFY FOR:
Receive energy-saving home
improvements at no cost that
HELP FOR
help you save money and make
socalgas.com/improvements
YOUR HOME
you more comfortable
1-800-331-7593
Get additional natural gas at
MEDICAL BASELINE
the lowest baseline rate if you
HELP FOR
socalgas.com/medical
have a serious health condition
MEDICAL NEEDS
1-866-431-3517
LOW INCOME HOME
Bill payment assistance,
ENERGY ASSISTANCE
emergency bill assistance and
HELP WITH
weatherization services
YOUR BILL
1-866-675-6623
CALIFORNIA LIFELINE
Discounted telephone services
For more information contact your
for eligible
customers
HELP WITH
telephone service provider
YOUR PHONE
FOR MORE INFORMATION ON CUSTOMER ASSISTANCE:
English: 1-800-427-2200 한국어: 1-800-427-0471
Español: 1-800-342-4545 廣東話: 1-800-427-1420
FAX: 213-244-4665 Việt: 1-800-427-0478
Hearing Impaired (TDD/TTY): 1-800-252-0259 中文: 1-800-427-1429
(available in English and Spanish only)
© 2019 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. SOURCE CODE: 9Q LARGE FONT
N19E0032A
PAGE 4 OF 7
CARE APPLICATION 20% DISCOUNT
PLEASE USE DARK BLUE OR BLACK INK ONLY
Please complete and return the 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
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
- -
Total number of persons in your household
(include yourself, other adults, and children):
1 2 3 4 5 6
If more than 6:
PAGE 5 OF 7
1
$0 – $33,820
$33,821 – $42,660
$42,661 – $51,500
$51,501 – $60,340
$60,341 – $69,180
NO (If no, what is your yearly household income before
deductions, including all members of the household?)
If more than $69,180, enter the dollar amount here
2
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
)
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
.00
per year.
$
,
PAGE 6 OF 7
2
(continued)
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
3
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
Source Code: 9Q
PAGE 7 OF 7
Form 6491 EN 0619 Meter: Residential
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Completed 7 November 2020

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