Contact Information

Last Name *

First Name *

M.I.

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

QUALIFICATIONS FOR TAX EXCEMPTION

Are you enrolled in Pacific Gas & Electric Company's (PG&E) CARE Program (California Alternate rates for Energy program)

Are you enrolled ?

Yes

If you answered no, please fill out the low income or senior excemption form(if applicable)

UTILITY INFORMATION - Does not apply to water , sewer, and garbage.

Utility 1 *

Account Number 1 *

Name on account 1 *

Utility 2

Account Number 2

Name on Account 2

Utility 3

Account Number 3

Name on Account 3

Utility 4

Account Number 4

Name on Account 4