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Is your Total Gross Household Income, (Income from all sources for all residents in the household at or below the <br />amounts shown below for your household size? <br />Please circle one: Yes No If you answered yes you qualify for this program. <br />Number in Household Gross Annual Income <br />I or 2 <br />$18,200 <br />3 <br />21,500 <br />4 <br />25,800 <br />5 <br />30,100 <br />6 <br />34,400 <br />7 <br />38,700 <br />Each additional member add <br />4,300 <br />Check sources that make up your total Gross Household Income <br />IMPORTANT: FOR VERIFICATION PURPOSES, PLEASE SUBMIT A COPY OF YOUR MOST <br />RECENT INCOME TAX PAPERS IF FILED. IF NOT, THEN PROVIDE COPIES SHOWING PROOF OF <br />ANNUAL INCOME FROM ABOVE MARKED SOURCES. PLEASE REVIEW APPLICATION TO <br />MAKE SURE THAT OT IS COMPLETE. UPON APPROVAL YOUR ACCOUNT WILL BE CREDITED <br />DURING THE NEXT BILLING CYCLE, AN AMMOUNT EOUAL TO YOUR TOTAL CURRENT <br />ELECTRIC USAGE CHARGE. <br />BY SIGNING BELOW, I CERTIFY: <br />I . I am not claimed on another persons income tax return. <br />2. 1 understand that Colton Electric Utility reserves the right to verify my household income. <br />3. Total number of people, including my self, living in my house is: <br />4. My total household income each year is: $ <br />5. That all information provided is correct under penalty of pe�ury under laws of California. <br />6. If I fail to provide requested income documentation or receive exemptions for which I am not eligible, my <br />account will be re -billed for credits I received. <br />Signature of Head of Household <br />FOR MORE INFORMATION CALL (909) 370-5555 <br />Date <br />