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 NONPROFIT GROUP LIVING FACILITIES
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 of nonprofit group living facilities that meet the program criteria established by the
California Public Utilities Commission (CPUC). The discounted rate is available to qualified facilities
once SoCalGas
®
receives and approves the application.
INSTRUCTIONS:
1
READ the information on pages 2 and 3. If you have questions,
call SoCalGas at 1-800-427-2200.
2
DETERMINE if the facility meets the definition of a “qualified
nonprofit group living facility”. The facility MUST meet ALL
criteria to qualify for the 20% monthly discount.
3
COMPLETE and SUBMIT the entire application (please print).
Complete a separate application for each qualified facility
(including satellite facilities).
4
ATTACH all required documents. Application will not be
approved without all requested documentation.
5
MAIL TO:
SoCalGas
CARE PROGRAM GT19A1
PO BOX 513249
LOS ANGELES, CA 90051
(continued)
socalgas.com
1-800-427-2000
FORM 6571
FOR QUALIFIED NONPROFIT GROUP LIVING FACILITIES
ELIGIBLE FACILITIES
Nonprofit Group Living Facilities:
If you are operating a women’s shelter, homeless shelter, hospice or a nonprofit group living facility,
your facility may be eligible to save on its monthly natural gas bill. Eligible group living facilities may
include transitional housing (drug rehabilitation facilities, half-way houses), short-term or long-term
care facilities (hospice, nursing homes, senior’s or children’s homes) or group homes for physically
or mentally disabled persons.
To receive this assistance, the facility must:
• Have tax-exempt status under Internal Revenue Code Section 501(c)(3).
• Use at least 70 percent of the facility’s natural gas consumption for
residential purposes.
• Re-certify eligibility every two years to remain enrolled in the program.
• Use the CARE discount for the direct benefit of the facility’s residents.
• Ensure that all of the facility’s residents meet the CARE eligibility guidelines
(as shown in the chart below).
Satellite Facilities:
• A nonprofit group living facility may consist of a licensed primary facility and related
non-licensed facilities at other locations (satellites).
• The primary facility must be licensed by the appropriate state agency or provide adequate proof
of eligibility and meet all other CARE criteria.
• At least 70 percent of the natural gas used at the satellite facility must be for residential purposes.
• The primary licensed facility’s name must appear as the customer-of-record on the natural gas bill
for the satellite facility.
FACILITIES NOT ELIGIBLE
• Group living facilities offering only a place to live and no other services.
• Nonprofit facilities providing social services only.
• Student housing/dorms, military barracks, fraternities/sororities, privately owned for-profit
housing, and government-subsidized housing.
• Government-owned and/or government-operated facilities.
(continued)
2
FOR QUALIFIED NONPROFIT GROUP LIVING FACILITIES
HOW TO QUALIFY/RECERTIFY
For the CARE program
THERE ARE TWO WAYS TO QUALIFY
PUBLIC ASSISTANCE PROGRAMS
The individual resident in the facility receives benefits
from any of the following programs:
Number of Persons in Household Total Annual Income
*
MAXIMUM HOUSEHOLD INCOME
(Effective June 1, 2020 to May 31, 2021)
OR
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
For each additional household member, add $8,960
*Includes current household income from all sources before deductions.
$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
Approved facilities are required to recertify for the CARE program upon request. An application will
be mailed when it is time to recertify. Facilities must include total savings from the prior year and
information on how the discount was used for the direct benefit of the qualified residents.
QUALIFICATION REQUIREMENTS:
• Completed and signed application.
• A copy of IRS letter granting tax-exempt status of corporation operating the facility under Internal
Revenue Code Section 501(c)(3).
• Group living facility must provide a copy of license from appropriate state agency, conditional use
permit for each facility, OR other adequate proof of eligibility.
• Each facility must meet the CARE guidelines shown in the income chart above.
PLEASE PRINT PAGES 4 & 5
FOR 20% DISCOUNT CARE APPLICATION
(continued)
3
20% DISCOUNT CARE APPLICATION
FOR QUALIFIED NONPROFIT GROUP LIVING FACILITIES
PRIMARY FACILITY ACCOUNT INFORMATION: (please print)
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:
Primary contact: Email:
Phone: Fax:
( )
Group living facility, total number of residents at this facility:
Hospice Homeless shelter Women’s shelter Number of beds: Number of days occupied each year:
Other: Total number of residents at this facility:
PRIMARY SERVICES OFFERED BY THE FACILITY
Lodging Meals Rehabilitation Training Counseling
Is at least 70% of the natural gas used at the facility for residential purposes? YES NO
Does nonprofit corporation operation facility have a tax-exempt status under YES NO
Internal Revenue Section 501(c)(3)?
Is the facility government-owned or operated? YES NO
Name of Business License
(Please attach a copy of the State-Issued License or other adequate proof of eligibility for each facility):
Name on Conditional Use Permit
(Please attach a copy of the Conditional Use Permit or other adequate proof of eligibility for each facility):
Other:
ALL QUALIFIED SATELLITE FACILITIES (if applicable)
Facility name: Account number:
Service address: Satellite facility: YES NO
Group living facility Total number of residents at this facility:
Hospice Homeless shelter Women’s shelter Number of beds: Number of days occupied each year:
TYPE OF FACILITY
Total number of residents who are qualified:
(see Individual Eligibility Guidelines)
Total number of residents who are qualified:
(see Individual Eligibility Guidelines)
Total number of residents who are qualified:
(see Individual Eligibility Guidelines)
Is at least 70% of the natural gas used at the facility for residential purposes? YES NO
(continued)
4
20% DISCOUNT CARE APPLICATION
FOR QUALIFIED NONPROFIT GROUP LIVING FACILITIES
ALL QUALIFIED SATELLITE FACILITIES (continued)
Facility name: Account number:
Service address: Satellite facility: YES NO
Group living facility Total number of residents at this facility:
Total number of residents who are qualified:
(see Individual Eligibility Guidelines)
Hospice Homeless shelter Women’s shelter Number of beds: Number of days occupied each year:
Is at least 70% of the natural gas used at the facility for residential purposes? YES NO
Facility name: Account number:
Service address: Satellite facility: YES NO
Group living facility Total number of residents at this facility:
Total number of residents who are qualified:
(see Individual Eligibility Guidelines)
Hospice Homeless shelter Women’s shelter Number of beds: Number of days occupied each year:
Is at least 70% of the natural gas used at the facility for residential purposes? YES NO
CERTIFICATION OF ELIGIBILITY
I certify, under penalty of perjury, under the laws of the State of California, that the information on
this application is true and accurate. I am authorized by this facility to sign this application, and I
have verified the income eligibility of all residents. I am responsible for the renewal of the facility’s
license from the appropriate State Licensing Department, or for the Conditional Use Permit, or to
provide adequate proof of eligibility. I understand that Southern California Gas Company may verify
the accuracy of this information and confirm the direct benefit to the residents through random
samplings. Errors in any information provided may cause the account(s) to be re-billed without the
CARE discount.
NOTICE TO CUSTOMER: Signing this application allows SoCalGas to share your CARE information
with other utilities, so that you may receive their discount, if applicable.
Authorized representative’s name and title (please print):
Authorized representative’s signature:
Date:
Authorized representative’s telephone number:
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.
N20E0097A 0420
5
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Completed 28 May 2021

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