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Applicant Information: First Name Last Name Initial Street Address / Unit Number City State Zip Home Phone Number Work or Cell Phone Number What is Your Preferred Language for Communication? English Spanish Vietnamese Other Are you: 62 years of age or older? Long-term disabled? Military Veteran? Are you the customer of record or listed as a responsible party on the account? Yes No From Your Anaheim Public Utilities Bill: (Mobile Home Residents, see page 2) Customer Account Number: Electrical Customer of Record Account Information: (if same information as Applicant Information, write “same as above”) First Name Last Name Street Address / Unit Number City State Zip Home Phone Number Work or Cell Phone Number Household Information: Name Date of Birth Annual Income Before Taxes Head of Household: $ Others living in the household: $ $ $ $ Total Household Income Before Taxes $ (Continued on page 2) ANAHEIM PUBLIC UTILITIES INCOME-QUALIFIED ENERGY DISCOUNT PROGRAM FOR SENIOR, LONG-TERM DISABLED, OR MILITARY VETERAN CUSTOMERS ---PAGE BREAK--- A) Current Living Status: Own House/Condo/Town House/Mobile Home (for Mobile Home, go to section B) or Rent House/Condo/Town House/Mobile Home (for Mobile Home, go to section B) B) For Mobile Home Residents: Name of Mobile Home Park: Is your Mobile Home unit individually metered for electric use? Yes No Do you receive your electrical bill from park management? Yes No Authorization from mobile home park owner/manager to receive Income-Qualified Energy Discount at master meter and provide savings directly to qualified senior: Name of owner/manager: Mobile Home Park Anaheim Public Utilities Customer Account (located on bill) Signature of owner/manager: Authorization (title): IMPORTANT NOTE: In order to qualify for the energy discount you must be listed as a responsible party (must be at least 18 years of age) on the Anaheim Public Utilities electric account. Senior, long-term disabled, or military veteran customers are eligible for a maximum 10% discount on the electric charges of the Utilities bill. If you already receive the senior/long-term disabled/military veteran energy discount, you cannot apply for an additional 10% credit. Please review application to make sure it is complete. By signing this application, you are certifying that all information you have provided is accurate and complete. You are certifying that you have accurately reported your income and your legal residence. If you are claiming a disability, you must attach a copy of your latest SSI statement or a letter from your physician in order to obtain the energy credit and must be listed as a Responsible Party on the electric account. You must attach a copy of identification proving your age is at least 62 years old to be eligible as a senior or a copy of either a DD-214, Veteran Health Identification Card (VHIC), or Common Access Card to be eligible as a military veteran. Please allow at least 30 days for processing and activation of your energy discount. Upon approval, you will receive the Energy Credit on your next billing cycle. Anaheim Public Utilities Electrical Customer of Record Signature Date Please mail the completed application to: Anaheim Public Utilities • Energy Discount Program • P.O. Box 3222 • Anaheim, CA 92803-9987 Questions? Call (714) 765-4250 Revised 2.5.16 SIGN