ClearForms Demo
Back

(Sample) UTILITY USER'S TAX EXEMPTION/ELECTRIC & WATER LIFELINE RATE APPLICATION

Aug 11, 2021
submission #14
Submit application

Your information

First Name ---
Middle Name/ Initial ---
Last Name ---
Service Address ---
Best contact phone number ---
Type of residence Apartment/ Condo
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 Metero by T- Mobile
Upload phone bill ---
Confirm landline phone number ---

Cellular/ Mobile Phone Lifeline Services

I am requesting cellular/ mobile lifeline services Yes
Cellular/ Mobile service company Metro by T-Mobil
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.