Utility User'S Tax Exemption/electric & Water Lifeline Rate Application

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CITY OF LOS ANGELES
OFFICE OF FINANCE
UTILITY USER'S TAX EXEMPTION/ELECTRIC & WATER LIFELINE RATE APPLICATION
(Los Angeles City Residents Only)
FOR OFFICE USE ONLY
Please PRINT all information legibly
Mail completed application to:
MONTH
DAY
YEAR
CHECK ONE:
I AM FILING AS
DATE
Received
New Application
Senior Citizen
OFFICE OF FINANCE
Account Number
UTILITY TAX EXEMPTION UNIT
Name Change
Disabled Citizen
Address Change
P.O.BOX 53233
LOS ANGELES, CA 90053-0233
Re-Certification
ENTER SOCIAL SECURITY NUMBER BELOW
Middle Initial
Last Name
First Name
(For record keeping purposes only)
Service Address
Apartment No./Space
SINGLE RESIDENCE
MOBILE HOME
City
State
Zip Code
Area Code: Phone Number
Day Time Phone
Mailing Address (if different from above)
Apartment No./Space
MM
DD
YYYY
Date of Birth
City
State
Zip Code
PLEASE ENCLOSE A PHOTOCOPY OF YOUR MOST RECENT UTILITY BILL FOR EACH UTILITY FOR WHICH YOU ARE
REQUESTING AN EXEMPTION. THE EXEMPTION CANNOT BE GRANTED IF THE NAME THAT APPEARS ON THE UTILITY BILL IS
NOT THE SAME AS THE APPLICANT'S NAME
Dept. of Water & Power
First Name
Middle Initial
Last Name
Is service included in your rent?
Yes
No
Account Number
Electric
Water
Number of People in Household?
Lifeline services requested:
Southern California Gas
First Name
Middle Initial
Last Name
Is service included in your rent?
Yes
No
Account Number
Landline Telephone Service Provider
First Name
Middle Initial
Last Name
Service Company Name
Area Code: Phone Number:
Area Code: Phone Number:
Residence Telephone
Additional Telephone Within Same Household
Cellular Telephone Service Provider:
First Name
Middle Initial
Last Name
Service Company Name
Phone Number
Signature REQUIRED on Page 2

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