Scecomcarerecert – Fill Out and Use This PDF

Daytime Telephone Number (Please include area code)

Email Address:

Check here ONLY IF YOU NO LONGER QUALIFY to participate in either the CARE or FERA rate assistance program. Your account will be removed from the CARE/FERA program. If you checked this box, please proceed to Section 4; sign

and date at the bottom, then mail this form in the postage paid envelope provided.

Check here if TTY User / Hearing Impaired (English only)

1HOUSEHOLD INFORMATION: Total Number of persons in household (Do Not Leave Blank)

Adults_________ Children________ Total (Adult + Children) ________

2PUBLIC ASSISTANCE PROGRAM ELIGIBILITY: Please check () ALL programs you participate in. If you do not participate in any of the programs in this section, then be sure to complete Section 3.

3INCOME ELIGIBILITY: Please provide your total gross annual household income, and check () all income sources

4CARE/FERA 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 Southern California Edison Company 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. I understand that SCE can share my information with other utilities or their agents to enroll me in their assistance programs.

Customer Signature (same name as listed on the account): ___________________________________ Date: _______________

Customer Name (please print): ____________________________________________________

Indicate if you are a guardian or have Power-of-Attorney for the above account and provide a notarized copy of the Power-of-Attorney document.

By checking this box, I confirm the information provided is accurate, and agree to receive calls at the above number, through an automatic-dialing announcing device (ATDS), or a pre-recorded message from, or on behalf of, Southern California Edison for rebates, savings, or other low-income qualified program information. I understand that consent to receiving these calls is not required to enroll in this income-qualified program and that message and data rates may apply.

Return this form to Southern California Edison in the postage paid return envelope provided, or mail directly to:

Southern California Edison, CARE Dept., P.O. Box 9527, Azusa, CA 91702-9932