Smud Assistance Application Form – Fill Out and Use This PDF

Application for Energy Assistance Program Rate (EAPR)

CUSTOMER INFORMATION

How to Apply

1. Enter the number of people living in your

Last Name

First Name

home.

2. Enter the total monthly income for your

household.

3. Attach a copy of your income documentation.

Mailing Address

4. Sign and date the application, then mail

it along with your income documentation to:

City

State

Zip

Sacramento Municipal Utility District

EAPR, M.S. A203

P.O. Box 15830

SMUD Account Number

Or: Name of your Mobile Home Park

Sacramento, CA 95852-1830

(if your electricity is submetered)

1. HOUSEHOLD INCOME

 Please complete the following:

Eligibility Guidelines (effective June 1, 2014)

Persons in

Monthly Income

Annual

Number of people living in your home,

Household

Income

including adults and children under 18:

people

1-2

$ 2,622

$ 31,460

Total Monthly Household Income (Gross): $

3

$ 3,298

$ 39,580

4

$ 3,975

$ 47,700

5

$ 4,652

$ 55,820

2. INCOME DOCUMENTATION

6

$ 5,328

$ 63,940

Please attach copies of your income documentation

Each Additional

for everyone living in your home. The documents will

NOT be returned. Examples of income documentation

Members

$ 677

$ 8,120

include, but are not limited to:

•4 weeks of dated paystubs from within the past 2 months

•Benefit letters such as SSI, EDD, Welfare, Foodstamps, Pensions, Workers Compensation, etc.

•Most recent individual Income Tax Return (1040 pages 1 & 2 - adjusted gross income and signature required)

If you have any questions regarding appropriate income documentation, please visit our website at www.smud.org/financialassistance for more information or call 1-888-742-7683 for assistance.

3.DECLARATION AND SIGNATURE

The information on this application will be used to decide and verify my eligibility for help. My signature gives consent for this information to be shared with other ofices of the Federal, State, and County Governments, with my utility company, and with other utilities or their agents to enroll me in their assistance programs. I permit the proper change to my rate schedule and consent to annual eligibility veriication. I declare, under penalty of perjury, that the information on this application is true and correct.

X

Signature (person whose name appears on SMUD bill)

Date

©SMUD-2743 (without flyer) 4/14 Forms Management

To participate in EAPR:

✓Your SMUD bill is in your name and you live at the address that will receive the discount.

✓Your gross (before taxes) household income* is no more than the amounts listed in the eligibility guidelines on the front.

✓Your application is completed with your name, address, number of people living in your

home, monthly gross income, your signature and the date, and copies of your income documents.

*Gross household income is all money and non-cash beneits available for living expenses, from all sources, both taxable and nontaxable, before deductions, for all people who live in the home. This includes but is not limited to:

Wages or Salaries	Social Security, SSI, SSP, SSDI
Interest and/or Dividends from:	Veteran’s Beneits
Savings Accounts	Pensions
Stocks or Bonds	Annuities
Retirement Accounts	Insurance Settlements
Unemployment Beneits	Legal Settlements
Rental or Royalty Income	TANF (AFDC)
School grants, scholarships (or	Food Stamps
other aid used for living expenses)	Child Support
Proit from Self-Employment	Spousal Support
Disability Payments	Cash and/or Other Income
Workers Compensation

EAPR FAQs

Will my income documents be returned to me?

We’re not able to return your original documents, so please send COPIES of any income/beneit documentation with your application.

Once a completed and signed application with income documents are received by SMUD how long will it take to be processed?

A completed application package is usually processed within 2 – 4 weeks of being received. After you’ve been enrolled, the Energy Assistance Program Discount will be printed as a line item on your SMUD bill each month.

If I have more than one account in my name, can I have the EAPR discount on all of them?

No, the discount is only applied to your primary residence.

How long will I receive the discounted rate?

We typically ask customers to re-apply every 1 to 2 years. When it’s time to re-apply, we’ll mail a request to you, and the letter will explain all requirements.

What should I do if I no longer qualify for the discount?

If your income or circumstances change, and you no longer qualify, please give us a call at 1-888- 742-7683 to update your account.

© SMUD-2743 (Reverse) 10/11 Forms Management