Application

West Coast Gas Co., Inc. 9203 Beatty Drive
Sacramento, CA 95826-9702
(916) 364-4100

Committed to Safety and Service

Customer Information

WCG Account Number*

Your Name (As Shown On Wcg Bill)*

Home Address*

City, State, Zip*

Phone Number*

Email Address*

Number Of Persons Permanently Residing In Household:

Adults*

Children*

Total*

I Hereby Certify:

My name is on the WCG bill
I am not claimed on another person's income tax return
I will renew my application when requested by WCG

I will notify WCG if I no longer qualify for this rate
I understand that WCG reserves the right to verify my household's income

There Are 2 Ways To Qualify!

1. Public Assistance Program Eligibility

If you or someone in your household participates in any of the following programs, please select the programs below:

Medi-Cal / Medicaid
Medi-Cal for Families A&B (Healthy Families A&B)
Low Income Home Energy Assistance Program (LIHEAP)
Supplemental Security Income (SSI)

Women, Infants and Children (WIC)
National School Lunch Program (NSLP)
CalFresh / SNAP (Food Stamps)
CalWorks (TANF) / Tribal TANF
SMUD Energy Assistance Program Rate (EAPR)

OR

2. Income Eligibility

Maximum Gross Yearly Household Income Guidelines (Effective as of June 1, 2022)

Household Size	1-2	3	4	5	6	7	8
Gross Yearly Income	$39,440	$49,720	$60,000	$70,280	$80,560	$90,840	$101,120

For each additional person, add $10,280

Total Combined Gross Yearly Household Income:

Example: Current monthly income x 12 months = yearly household income

Declaration

I state that the information I have provided in this application is true and correct. I understand that I may be requested to provide updated documentation of eligibility at any time and agree to do so regardless of how I initially became eligible for the discount. I agree to inform West Coast Gas Company Inc. if I no longer qualify to receive the discount. I understand that if I receive the discount without qualifying for it, I may be required to pay back the discount I received.

Customer's Signature*

Date*

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