Fillable 20% DISCOUNT CARE APPLICATION The California Alternate Rates (SoCalGas)

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20% DISCOUNT CARE APPLICATION The California Alternate Rates (SoCalGas)

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PAGE 1 OF 7
The California Alternate Rates for Energy (CARE) program offers
eligible SoCalGas
®
customers a 20% discount on their monthly
natural gas bill. The discount will be applied to the monthly natural
gas bill following the date that the application is approved by
SoCalGas. If you are a submetered tenant, your property owner/
manager will be notified whether or not you are approved to
receive the discount.
Please submit a completed application by using one of the
methods listed below:
1) Visit socalgas.com/CARE and apply as a
submetered tenant.
2) Call 866-716-3452 anytime, 24 hours a day.
Please have your Facility ID ready.
3) Return the completed and signed form by mail or
fax to 213-244-4665.
20% DISCOUNT
CARE APPLICATION
PAGE 2 OF 7
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
PUBLIC ASSISTANCE PROGRAMS
If you or another person in your household receives benefits
from any of the following programs:
1
Includes Welfare-to-Work
OR
For each additional household member, add $8,960
*Includes current household income from all sources before
deductions.
Number of Persons in Household Total Annual Income
*
MAXIMUM HOUSEHOLD INCOME
(effective June 1, 2020 to May 31, 2021)
THERE ARE TWO WAYS TO QUALIFY
$34,480
$43,440
$52,400
$61,360
$70,320
$79,280
$88,240
1-2
3
4
5
6
7
8
CONDITIONS FOR PARTICIPATION:
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
PAGE 4 OF 7
© 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. SOURCE CODE: 9Q LARGE FONT N20E0042A 0320
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)
socalgas.com/Improvements
1-800-331-7593
For more information contact
your telephone service provider
MEDICAL BASELINE
CALIFORNIA LIFELINE
1-866-675-6623
LOW INCOME HOME
ENERGY ASSISTANCE
socalgas.com/Medical
1-866-431-3517
Discounted telephone services
for eligible
customers
HELP FOR
YOUR HOME
HELP FOR
MEDICAL NEEDS
HELP WITH
YOUR BILL
HELP WITH
YOUR PHONE
Receive energy-saving home
improvements at no cost that
can help you save money and
make you more comfortable
Get additional natural gas
at the lowest baseline rate if
you have a serious health
condition
Bill payment assistance,
emergency bill assistance
and weatherization services
OTHER PROGRAMS AND SERVICES
YOU MAY QUALIFY FOR:
MASTER ACCOUNT NUMBER FACILITY ID
CUSTOMER NAME (FIRST AND LAST AS IT APPEARS ON YOUR BILL)
ADDRESS SPACE #
CITY
PRIMARY PHONE
PLEASE USE DARK BLUE OR BLACK INK ONLY
Please complete and return the 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
- -
1
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
PLEASE PROVIDE YOUR MASTER ACCOUNT AND FACILITY ID TO
EXPEDITE THE PROCESS.
CARE APPLICATION 20% DISCOUNT
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.
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
2
PAGE 6 OF 7
$0 – $34,480
$34,481 - $43,440
$43,441 - $52,400
$52,401 - $61,360
$61,361 - $70,320
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
PAGE 7 OF 7
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
Form 6677 EN Lrg Font
Meter: Submetered
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20% DISCOUNT CARE APPLICATION The California Alternate Rates (SoCalGas)

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Completed 28 May 2021

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