Fillable City of Banning Low Income Assistance Application (City of Banning)

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City of Banning Low Income Assistance Application (City of Banning)

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City of Banning
Low Income Assistance Application
Current Rate:
Section 1.
Customer
Info.
First Name Last Name M.I
Date of Birth: -____________
Address City State Zip Code
Banning, CA 92220
Daytime Phone #
( )
Utility Account Number: (REQUIRED)
__
How many in each group (including self)?
1. 0-5 yrs. old ________ 2. 6-18 yrs. old _______
3. 19-61 yrs. old ________ 4. 62+ yrs. old _______
Disabled
________
Gross
Total # of People in Household
(Including Applicant):
Section 2.
Source(s)
of
Income
Type of Household Income
Monthly
Income
1. Paychecks (Gross Salary, Wages, and gross income from self-employed)
$
2. Public Assistance (Cash Aid, CalFresh - Food Stamps, TANF, Cal Works, etc.)
$
3. Social Security Benefits, Supplemental and/or Disability
(Please add if both benefits are granted)
$
4. Pensions and Insurance Payments (Retirement Benefits, Insurance Benefits, Disability
Insurance, Workers Compensation, Unemployment Insurance, etc.)
$
5. All other income, please specify (Child Support or Alimony, Investment/Interest Income,
Foster Care Grant, Student/Financial Aid, etc.)
$
Total:
$
Section 3.
Applicant’s
Signature
1. I hereby authorize the City of Banning to do all of the following:
a. To examine all employment, income, utility, and other records pertinent to my application for energy
assistance.
b. To make direct credit to my Utility Account.
2. I understand that the reduction will be calculated by the electric charge and the electric consumption
portion of the bill.
3. ALL SUPPORTING DOCUMENTS MUST BE INCLUDED IN ORDER TO
PROCESS APPLICATION.
I certify under penalty of perjury that all information herein is true and correct to the best of my knowledge.
→
Applicant’s Signature Date
Section 4.
City of
Banning
Approval
CITY OF BANNING OFFICE USE ONLY
Rate Change: _______________
Public Benefits Coordinator’s Signature Date
Mail To: City of Banning, Public Benefits, 176 E. Lincoln St, Banning, CA 92220
Email to PublicBenfits@banningca.gov (951) 922-3260
www.ci.banning.ca.us
Revised 4/2/20
Low Income Assistance Program
PROGRAM DESCRIPTION:
The Low Income Qualified Discount is a program established by the City of Banning to assist
qualified low-income city residents with their electric bill. The program is administered by the
City of Banning and is funded by the state mandated Electric Public Benefits Charge. Upon
approval, qualified applicants will be put on the Low Income Qualified Discount, which will
result in an annual discount of up to $360 on the electric portion of their utility bill. Participants
must re-apply every two years. Low Income Qualified Discount funds are available to City of
Banning households who meet the following requirements and income guidelines.
REQUIREMENTS:
THE FOLLOWING IS REQUIRED TO APPLY FOR ASSISTANCE:
(Failure to provide the necessary documentation will be grounds for rejection of application)
• Applicants must have a current City of Banning electric account that has been active for a
minimum of twelve (12) months. Senior Citizens, 62 years of age or older, and disabled
individuals are exempt from this requirement.
• Must meet income eligibility guidelines as indicated below.
• Provide copy of current, valid, Driver’s License or California I.D.
• Provide documentation of income from all sources for everyone in the household during
the most recent four week period, which may include:
Paycheck Stubs, Social Security Award Letter, Unemployment Check Stubs, Current
Cash Aid/Cal Fresh Notice of Action or Award Letter, Disability Insurance
Payments, Alimony, Child Support, Workers Comp, Retirement Benefits,
Investment/Bank/Insurance Statements, etc.
• If self-employed, please provide all copies of current Form 1040 and Schedule C income
tax forms. Also, enter the amount on line 7 (Gross income) from schedule C, under
Household Information of Low Income Qualified Discount application.
Income Guidelines:
Household Size
Total Gross Monthly Income*
Does Not Exceed
Total Gross Yearly Income*
Does Not Exceed
1
$2,655
$31,860
2
$2,655
$31,860
3
$3,345
$40,180
4
$4,040
$48,500
5
$4,735
$56,820
6
$5,425
$65,140
7
$6,120
$73,460
8
$6,815
$81,780
* Income levels are based on the Federal Poverty Guidelines and are subject to change.
All supporting documentation must be included in order to process application
City of Banning, Public Benefits, 176 E. Lincoln St., Banning, CA 92220
(951)922-3260
www.ci.banning.ca.us
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City of Banning Low Income Assistance Application (City of Banning)

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Completed 21 September 2021

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