Fillable 20% DISCOUNT CARE APPLICATION (SoCalGas)

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20% DISCOUNT CARE APPLICATION (SoCalGas)

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20% DISCOUNT CARE APPLICATION
FOR QUALIFIED AGRICULTURAL EMPLOYEE HOUSING FACILITIES
1-800-427-2000
socalgas.com
APPLICATION FOR CALIFORNIA ALTERNATE
RATES FOR ENERGY (CARE) PROGRAM
The California Alternate Rates for Energy (CARE) program provides a 20% monthly
discount on the natural gas bill for agricultural employee housing facilities that meet program
criteria established by the California Public Utilities Commission (CPUC). The discounted rate is
available only to qualified facilities once SoCalGas
®
receives and approves the application.
READ the information on pages 2 and 3. If you have questions,
call SoCalGas at 1-800-427-2200.
DETERMINE if the facility meets the definition of a “qualified
agricultural employee housing facility.” The facility MUST
meet ALL criteria to qualify for the 20% monthly discount.
COMPLETE and SUBMIT the entire application (please
print). Complete a separate application for each qualified
facility (including satellite facilities).
ATTACH all required documents. Application will not be
approved without all requested documentation.
MAIL TO:
SoCalGas
CARE PROGRAM GT19A1
PO BOX 513249
LOS ANGELES, CA 90051
FORM 6632
INSTRUCTIONS:
1
4
2
5
3
(continued)
2
EMPLOYEE HOUSING (privately owned), as defined in section 17008 of the California Health
and Safety Code, that is licensed and inspected by state and/or local agencies pursuant to Part I
(commencing with Section 17000) of Division 13.
Supporting documentation required:
Provide copy of current permit issued by the Department of Housing and Community Development.
Total energy used:
Must be 100 percent residential use.
ELIGIBLE FACILITIES
FOR QUALIFIED AGRICULTURAL EMPLOYEE HOUSING FACILITIES
ELIGIBILITY CRITERIA FOR APPLICANT
Each applicant MUST meet all of the following criteria:
• Applicant must be SoCalGas’ customer of record.
• Applicant must verify that 100 percent of the household meets the current CARE income
guidelines, excluding any employee operating or managing the facility who resides at the facility.
• Applicant is required to recertify for the CARE program annually. An application will be mailed
when it is time to recertify. Applicant must include total savings from the prior year and
information on how the discount was used for the direct benefit of the qualified residents.
(continued)
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
The individual resident in the facility receives benefits
from any of the following programs:
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)
OR
$34,480
$43,440
$52,400
$61,360
$70,320
$79,280
$88,240
1-2
3
4
5
6
7
8
1
Includes Welfare-to-Work
THERE ARE TWO WAYS TO QUALIFY
3
The applicant is required to:
• Provide proof of facility’s eligibility (see Eligible Facilities) and submit required documentation with
the application (see requirements on the application).
• Verify that all individuals residing in the facility meet the CARE income eligibility guidelines (see
income guideline chart) and make a certification to that effect, under penalty of perjury, under the
laws of the state of California.
• At annual recertification, show how the past year’s discount was used and how the next year’s
discount is expected to be used for direct benefit of the residents.
• Maintain records of residents’ income eligibility, which should come from federal tax return, payroll
stubs or similar records acceptable to SoCalGas. These records must be retained for three years
from the date of initial application and/or recertification.
• Maintain accounting entries and supporting documentation of how the discount was used for the
direct benefit of the residents. These records must be retained for three years from the date of
initial application and/or recertification.
• Upon request from SoCalGas, provide documentation of the residents’ income eligibility and/or
documentation of how the discount was used for the direct benefit of the residents.
• Provide all information requested by SoCalGas. Failure to do so will result in denial or removal from
the program. The applicant may be subject to rebilling for the period they were ineligible for the
discount as determined by SoCalGas.
APPLICANTS’ RESPONSIBILITIES
PLEASE PRINT PAGES 4 THROUGH 6
FOR 20% DISCOUNT CARE APPLICATION
FOR QUALIFIED AGRICULTURAL EMPLOYEE HOUSING FACILITIES
HOUSING FOR AGRICULTURAL EMPLOYEES (non-migrant and operated by nonprofit entities),
as defined in Subdivision (b) of Section 1140.4 of the California Labor Code, that has an exemption
from local property taxes pursuant to subdivision (g) of Section 214 of the California Revenue and
Taxation Code.
Supporting documentation required:
Provide current copy of federal 501(c) (3) tax exemption or copy of state tax exemption form, and
current copy of local property tax exemption form.
Total Energy used:
• Master-metered facilities must be 70 percent residential use.
• Individually metered units must be 100 percent residential use.
ELIGIBLE FACILITIES (continued)
(continued)
FOR ALL FACILITIES
Applicant is customer of record. Yes No 100% of household meets care income guidelines. Yes No
I have provided information on how the discount for the coming year will be used to directly benefit the residents. Yes No
For recertification, I have provided information on how the discount was used for the direct
benefit of the residents and I have documentation on file (if initial certification, leave blank). Yes No
I understand the utility reserves the right to request documentation on the eligibility of the
residents and the use of the discount. Yes No
I understand the utility has the right to rebill me at the applicable rate if appropriate. Yes No
I understand if the facility(ies), or the residents, become(s) ineligible to received the discount
I must notify the utility within 30 days. Yes No
Last year’s discount was used for (if initial certification leave blank):
This year’s discount will be used for:
FACILITY INFORMATION (check one)
(continued)
4
EMPLOYEE HOUSING (privately owned), as defined in Section 17008 of the California
Health and Safety Code, that is licensed and inspected in state and/or local agencies
pursuant to part 1 of Division 13.
HOUSING FOR AGRICULTURAL EMPLOYEES (non-migrant and operated by nonprofit
entities), as defined in Subdivision (b) of Section 1140.4 of the California Labor Code, that
has received exemptions from local property taxes pursuant to subdivision (g) of the
California Revenue and Taxation Code.
20% DISCOUNT CARE APPLICATION
FOR QUALIFIED AGRICULTURAL EMPLOYEE HOUSING FACILITIES
Name on natural gas bill: Account number:
Name of facility (if different from name on natural gas bill):
Service address: City: State:
Mailing address: City: State:
Facility contact name: Email:
Phone: ( ) Fax:
( )
APPLICANT INFORMATION: (please print)
5
20% DISCOUNT CARE APPLICATION
FOR QUALIFIED AGRICULTURAL EMPLOYEE HOUSING FACILITIES
ALL QUALIFIED SATELLITE FACILITIES (if applicable):
(continued)
Facility name: Account number:
Service address: City: Zip:
Mailing address: City: Zip:
Facility contact: Phone: Email:
Type of metering: Individually metered Master metered Energy used for residential purpose: 100% At least 70%
Total number of residents (exclude on-site manager):
100% of residents and/or households meet income eligibility criteria: YES NO
Facility name: Account number:
Service address: City: Zip:
Mailing address: City: Zip:
Facility contact: Phone: Email:
Type of metering: Individually metered Master metered Energy used for residential purpose: 100% At least 70%
Total number of residents (exclude on-site manager):
100% of residents and/or households meet income eligibility criteria: YES NO
Facility name: Account number:
Service address: City: Zip:
Mailing address: City: Zip:
Facility contact: Phone: Email:
Type of metering: Individually metered Master metered Energy used for residential purpose: 100% At least 70%
Total number of residents (exclude on-site manager):
100% of residents and/or households meet income eligibility criteria: YES NO
DECLARATION
By signing this application, I certify under penalty of perjury under the laws of the State
of California that the information I have provided is true and accurate. I have:
• Verified that the income eligibility of all residents of the facility and/or households meet
income guidelines.
• Verified that documentation is available to substantiate the above application.
• Verified that each facility meets the residential energy usage criteria.
• Read and understand this application, and agree to abide by its terms and the terms of the
CARE program.
By signing this application, I give my consent that the information provided by me may be shared with other energy
utility companies (limited to name and address).
20% DISCOUNT CARE APPLICATION
FOR QUALIFIED AGRICULTURAL EMPLOYEE HOUSING FACILITIES
ALL QUALIFIED SATELLITE FACILITIES (continued)
Return to:
SoCalGas
CARE PROGRAM GT19A1
P.O. Box 513249
Los Angeles, CA 90051-1249
© 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 SoCalGas 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.
N20E0098A 0320
6
Facility name: Account number:
Service address: City: Zip:
Mailing address: City: Zip:
Facility contact: Phone: Email:
Type of metering: Individually metered Master metered Energy used for residential purpose: 100% At least 70%
Total number of residents (exclude on-site manager):
100% of residents and/or households meet income eligibility criteria: YES NO
Authorized representative’s name and title (please print):
Authorized representative’s telephone number:
Authorized representative’s signature:
Date:
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Completed 28 May 2021

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