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City of Colton Electric Utility <br />Residential Low Income Assistance Program <br />HEAD OF HOUSEHOLD: <br />Last Name First Name Middle Initial <br />SOCIAL SECURITY NUMBER OF HEAD OF HOUSEHOLD: <br />CITY OF COLTON UTILITIES ACCOUNT — CUSTOMER ON RECORD INFORMATION <br />Last Name <br />Home Phone # <br />First Name <br />Work/Message Phone # <br />Middle Initial <br />Date of Birth <br />Service Address city State ZIEP <br />ELECTRIC UTILITIES ACCOUNT NUMBER: <br />Household Information <br />Social Security # <br />Date of <br />Birth <br />Age <br />Annual Income <br />Before Taxes <br />Filed Tax <br />(Y/N) <br />Head of Household Name: <br />I . <br />$ <br />Who is living with you? <br />2. <br />$ <br />3. <br />$ <br />4. <br />5. <br />$ <br />6. <br />$ <br />7. <br />$ <br />8. <br />$ <br />(Use back of application if household <br />is larger than eight (8) <br />Total Family Income Before Taxes <br />$ <br />