Application for Sewer Lifeline Rate Assistance Program
Application Instructions
Step 1 - Complete all of the blue boxes below. Your application won't be processed without this information.
Step 2 - Select either the Print OR Mail Application Option below.
Step 3 - Select the Submit Application button
Your application will be validated
Make any requested corrections
Step 4 - Finish the application submission process by following the steps listed in the Application option you chose below.
Please provide your information
First Name :
Middle Name :
Last Name :
Phone Number :
Email Address :
Customer Type :
I certify that the utility bill is in my name
Please provide your property address
Street Number :
Street Name :
Apt/Ste :
City :
State :
Zip :
Property Type :
Copy property address to mailing address
Address entered is not valid. Please verify and resubmit.
Please provide your mailing address
Street Number :
Street Name :
Apt/Ste :
PO Box :
City :
State :
Zip :
Address entered is not valid. Please verify and resubmit.
Please provide your monthly income details
Enter the total GROSS monthly income for everyone living in your home and attach current proof of income. Proof of income documentation
*
must match the amount on the TOTAL GROSS INCOME line below.
Number of persons living in home :
CalWORKS $
Spousal Support $
SSI/SSP $
Unemployment $
SSA $
Pensions $
SDA $
Wages $
TANF $
Interest Income $
Child Support $
Other Income $
I certify my family total gross income meets the income eligibility requirements.
TOTAL GROSS INCOME $
*
Blacken out your Social Security and banking numbers in all documentation before mailing. Your personal documents will not be returned to you.
Print Application
Print Application Option
1. Print Application.
2.
Sign and date the completed application.
3. Attach a copy of your sewer bill or monthly mobilehome park rental bill.
4. Attach income documentation or a copy of your SMUD or PG&E bill as proof of participation in their rate assistance programs.
5. Mail application and documentation to:
Sewer Lifeline Rate Assistance Program
10060 Goethe Road,
Sacramento, CA 95827
Mail Application
Mail Application Option
1. Your application will be printed and mailed back to you at the mailing address provided on the application.
2. Complete any missing information as requested.
3.
Sign and date the completed application.
4. Attach a copy of your sewer bill or monthly mobilehome park rental bill.
5. Provide your income documentation or a copy of your SMUD or PG&E bill as proof of participation in their rate assistance programs.
6. Mail the application and documentation back to the Sewer Lifeline Rate Assistance Program using the stamped self-addressed envelope provided.
Submit Application