Tx Lite Up – Fill Out and Use This PDF

Low-Income Telephone and Electric Discount Programs Enrollment Form (LITE-UP) For Questions, Call LITE-UP Texas toll-free at 1-866-454-8387

Full Name _______________________________

Address 1 _______________________________

Address 2 _______________________________

City, State Zip_______________________________

ABOUT THE PROGRAMS

The Telephone Discount Program

•Available to qualified low-income customers.

•Also available if a resident member of your household is a recipient of a qualified program.

•The Program can provide a discount up to $13.50 off your telephone bill.

•Your discount will appear on the next telephone bill after your completed application and documentation have been approved.

The Electric Discount Program

•Available to qualified low-income customers.

•The program can provide a discount on your electric bill if you live in an area where you have a choice of electricity provider.

•The electric discount program is a five month program.

•The discount will be on the May thru September bills ONLY, after your completed application and documentation have been approved.

Program Rules

•You must notify LITE-UP Texas in writing if you no longer qualify for the discount. Send notice to: LITE-UP Texas, 1779 Wells Branch Parkway, Suite 110B #357, Austin, TX 78728-7022.

•You must notify LITE-UP Texas to report any change in address or telephone number.

•You must provide a copy of your latest Telephone bill AND Electric bill with this application.

OPlease submit photocopies of all documents, original documents will not be returned.

•You must complete the applicable sections below as follows:

OSection 1 – This section must be completed by the person in whose name the service is billed. The person in whose name the electric service is billed must reside at the service address for this electric service.

OSection 2 – If applying for the LITE-UP Program based on income, then your total household gross income must be at or below the applicable level indicated in the application:

You must provide proof of income.

This section must be completed by the person in whose name the telephone and/or electric service is billed.

OSection 3 - If the person receiving the Eligible Benefits is a different resident household member than the person whose name is on the telephone bill, then the resident household member receiving the benefits must complete and sign Section 3. If the benefit recipient is a minor child, then one of the minor child's parents must complete and sign this section for the minor child. The person receiving the eligible benefit(s) must provide proof that he/she participates in one of the eligible programs. Note: This is only applicable to Telephone Discounts.

OSection 4 – The person in whose name the telephone or electric service is billed must complete and sign this section.

SECTION1- Applicant Information

The person whose name is on the Telephone and Electric bills MUST fill out this section. The person in whose name the utility bills appear must live at the service address. For the Telephone discount ONLY, the qualifying resident member must live at the service address.

Name of Telephone Customer: _________________________________________________________

Address: _________________________________________________________________________________

City: ___________________________________________, TX Zip Code: ____________________

Telephone Number: ( __ __ __ ) __ __ __ - __ __ __ __ Social Security Number: __ __ __ - __ __ - __ __ __ __

YOU MUST INCLUDE A COPY OF YOUR LATEST TELEPHONE AND ELECTRIC BILLS

SECTION 2 – Income Enrollment

If applying for the Discount Programs based on income, your total household gross income must be less than the requirements listed below.

HOUSEHOLD SIZE – Total (Include all adults and children residing at this service address)

Number of people living in your household: ___ ___

HOUSEHOLD INCOME WORKSHEET

Your total household gross annual income from all sources cannot exceed these guidelines:

SECTION 3— Program Benefit Enrollment

Benefit Recipient – Telephone Discount Only

If the person receiving the Eligible Benefits listed above is a different resident household member than the person whose name is on the telephone bill, then the resident household member receiving the benefits must complete and sign Section 3. If the benefit recipient is a minor child, then one of the minor child's parents must complete and sign this section for the minor child. The person receiving the eligible benefit(s) must provide proof that he/she participates in one of the eligible programs.

Name of Benefit Recipient: ____________________________________________________________

Telephone Number: ( __ __ __ ) __ __ __ - __ __ __ __ Social Security Number: __ __ __ - __ __ - __ __ __ __

YOU MUST PROVIDE PROOF OF PROGRAM PARTICIPATION WITH THIS APPLICATION

SECTION4- Declaration (please read carefully and sign)

The person in whose name the utility service is billed must complete and sign this section.

By signing this form, I state that the information I have provided in this application is true and correct. I understand that the information provided is subject to audit and investigation by the Public Utility Commission of Texas.

Mail completed application and required documentation to:

LITE-UP Texas

1779 Wells Branch Parkway

Suite 110B #357

Austin, Texas 78728-7022