(Sample) UTILITY USER'S TAX EXEMPTION/ELECTRIC & WATER LIFELINE RATE APPLICATION
Sep 21, 2017
submission
#1
Submit application
Your information
| First Name | --- |
| Last Name | --- |
| Service Address | --- |
| Best contact phone number | --- |
| Type of residence | Single residence/ home |
| Number of people in household | --- |
| Date of Birth | --- |
| Last 4 digits of SSN | --- |
| I am requesting Lifeline services because I am | Both |
| My annual income in the last year | --- |
| Upload income verification document (tax return, etc.) | --- |
LADWP Lifeline services
| Are you requesting LADWP Lifeline services? | No |
| LADWP Account Number | --- |
| Lifeline services requested | Electric, Water, None |
| Is service included in your rent? | --- |
Southern California Gas Lifeline Service
| Are you requesting SoCal Gas Lifeline service? | Yes |
| SoCal Gas Account Number | --- |
| Is service included in your rent? | --- |
Landline Lifeline Services
| I am requesting lifeline services for my land line. | No |
| Phone service company name | 55555555555 |
Cellular/ Mobile Phone Lifeline Services
| I am requesting cellular/ mobile lifeline services | Yes |
| Cellular/ Mobile service company | jghhuopijoipj |
Cerficiation
| I certify uder penalty of perjury that the information I have provided is correct, and I agree to all the conditions set forth above. | I do not certify the information submitted above. |