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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 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 DUSK-TO-DAWN LIGHT INSTALLATION PROGRAM FOR INCOME-QUALIFIED CUSTOMERS ---PAGE BREAK--- A) Current Living Status: Own House/Condo/Town House/Mobile Home (for Mobile Home, go to section B, then C) or Rent House/Condo/Town House/Mobile Home (go to section C) 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 C) Note: Renters of single family homes must receive authorization from the owner. Mobile home-residents at master- metered parks must receive authorization from the property management to allow installation of light fixtures: 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 be eligible, you must be listed as a responsible party (must be at least 18 years of age) and the household income must be less than 80% of the Orange County median*. 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 you have not made any false representation herein. Some installation may not be feasible or exceed programs budgetary allowances. Please review application to make sure it is complete. Upon approval, you will be notified by telephone to schedule the free light installation. Printed Name of Electrical Customer of Record Signature Date *Please visit http://www.anaheim.net/1468/Dusk-to-Dawn-Lighting to see the current Income Guidelines (adjusted annually). Please mail the completed application to: Dusk to Dawn Installation • 201 S. Anaheim Blvd. Suite 801 • Anaheim, CA 92805 Questions? Call (714) 765-4250 Revised 04.22.16