Lite Up Texas Application Form Pdf Details

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QuestionAnswer
Form NameTx Lite Up
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other nameslite up texas, lite up texas application, texas lite up application, printable liheap application

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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: _________________________________________________________

As it appears on your utility bill

(please print)

Name of Electric Customer:

_________________________________________________________

If different from above

 

(please print)

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:

 

Number of persons in Household

1

 

2

 

3

4

5

6

7

8

 

Total Household annual income - Telephone

$15,600

 

$21,000

$26,400

$31,800

$37,200

$42,600

$48,000

$53,400

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Household annual income - Electric

$13,000

 

$17,500

$22,000

$26,500

$31,000

$35,500

$40,000

$44,500

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dollar

 

 

PROVIDE PROOF OF HOUSEHOLD INCOME WITH THIS

 

Income Source

 

Amount

 

 

APPLICATION (provide all documents that apply)

 

 

Wages from Employment as shown on pay

 

 

 

 

 

Copy of most recent pay stub(s) from all employers covering the

 

stub or W-2 Form

 

 

 

 

 

last two months (for all members of the household),

 

 

 

 

 

 

 

 

Your most recently filed tax return (must be signed) or W-2,

 

Social Security

 

 

 

 

 

 

 

 

 

 

 

A signed letter from each employer indicating the level of your

 

 

 

 

 

 

 

 

Retirement Income

 

 

 

 

 

 

 

 

 

 

 

wage,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alimony or Child Support

 

 

 

 

 

Documentation of social security income, Copy of an

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unemployment or Worker's Compensation

 

 

 

 

 

unemployment form with eligibility dates,

 

 

 

 

 

 

 

 

 

Copies of the two most recent unemployment checks

 

 

All Other Earnings

 

 

 

 

 

 

 

 

 

 

 

 

 

Copy of the most recent bank statement showing direct deposit of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

income.

 

 

 

 

 

SECTION 3— Program Benefit Enrollment

Enrollment in any of the programs listed below will qualify you for

Enrollment in any of the programs listed below will qualify you

the telephone discount.

for the Electric discount.

Food Stamps

Food Stamps

Medicaid

Medicaid

Supplemental Security Income-SSI

 

Health Benefit Coverage under Child Health Plan (CHIP)

 

Low-Income Energy Assistance Program - LIHEAP

 

Federal Public Housing Assistance

 

Eligible Resident of Tribal Lands (please indicate which tribe):

 

__________________________________________

 

Tribe Name

 

 

 

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: __ __ __ - __ __ - __ __ __ __

X

_____________________________________________________

Date: ________________________

 

Eligible Benefit Recipient Signature

 

X

_____________________________________________________

Date: ________________________

 

Parent's Signature if Eligible Recipient is a Minor Child

 

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.

X _____________________________________________________

Date: ________________________

Applicant’s Signature

 

Mail completed application and required documentation to:

LITE-UP Texas

1779 Wells Branch Parkway

Suite 110B #357

Austin, Texas 78728-7022