(Sample) UTILITY USER'S TAX EXEMPTION/ELECTRIC & WATER LIFELINE RATE APPLICATION
Jul 14, 2020
submission
#8
Submit application
Your information
| First Name | --- |
| Middle Name/ Initial | --- |
| Last Name | --- |
| Service Address | --- |
| Apartment Number | --- |
| Best contact phone number | --- |
| Type of residence | Mobile home |
| Number of people in household | --- |
| Date of Birth | --- |
| Last 4 digits of SSN | --- |
| Copy of your Driver's license or ID Card (for Senior age verification) | --- |
| I am requesting Lifeline services because I am | Senior citizen (over 62) |
| My annual income in the last year | --- |
| Upload income verification document (tax return, etc.) | --- |
LADWP Lifeline services
| Are you requesting LADWP Lifeline services? | Yes |
| LADWP Account Number | --- |
| Lifeline services requested | Electric, Water |
| Is service included in your rent? | --- |
| Upload a copy of your most recent LADWP bill | --- |
Southern California Gas Lifeline Service
| Are you requesting SoCal Gas Lifeline service? | Yes |
| SoCal Gas Account Number | --- |
| Is service included in your rent? | --- |
| Upload a copy of your most recent SoCal Gas bill | --- |
Landline Lifeline Services
| I am requesting lifeline services for my land line. | Yes |
| Phone service company name | VONAGE |
| Upload phone bill | --- |
| Confirm landline phone number | --- |
Cellular/ Mobile Phone Lifeline Services
| I am requesting cellular/ mobile lifeline services | Yes |
| Cellular/ Mobile service company | VERIZON WIRELESS |
| Upload cellular phone bill | --- |
| Confirm mobile phone number | --- |
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 certify the information submitted above. |