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2. First Name*
3. Last Name*
5. Address1*
7. City*
8. State*
9. Zip*
11. Telephone Number*
12. 2nd Telephone Number
13. Electric Utility Account Number*
15. Email*
17. How many people currently live in the home?*
18. What is the total combined household income?*
19. Did you file taxes for the current year? (Yes or No)*
21. Effective From 7/1/2024 to 6/30/2025 These are the income guidelines per number in household:

    Please add your initials to the income box that your household falls into.

23. 1 or 2 People < $40,880
24. 3 People < $51,640
25. 4 People < $62,400
27. 5 People < $73,160
28. 6 People < $83,920
29. Each Additional Person add $10,760
31. List the First and Last Name, Date of Birth, and Age of each person living in the home.*
    Example: 1. John Doe, DOB 1/15/1980, 40 yrs old
33. Please Read and Select a response to the following statements
35. I understand this program applies ONLY to the Electric portion of my utility bill.*
    -- Select One --YesNo
37. I understand the monthly savings will begin on my next month's bill.*
    -- Select One --YesNo
39. I understand I will be receiving a 25% discount each month for 12 consecutive months from date of approval*
    -- Select One --YesNo
41. As the account holder I am over the age of 65 and eligible for 37% discount*
    -- Select One --YesNo
43. Please list the sources that make up your total Gross Household Income.*
    (Examples Include: Wages/Salary, Child/Spousal Support, Cal WORKS, Social Security/Disability, Unemployment, Workers Compensation, Retirement Income, Rental Income, etc.)
45. IMPORTANT: For verification purposes, please attach all forms of proof of income. If someone over the age of 18 does not have proof of income or is not a full-time student, you must submit verification from the unemployment office.
    Proof of income includes; recent pay stubs or a copy of the income tax return. You must show proof of all forms of income listed above.
47. Upload proof of income*
48. Upload proof of income (if more than one)
50. Upload proof of income (if more than two)
51. Upload proof of income (if more than three)
53. By typing your name below, you are authorizing the City of Colton to verify your household income for the purposes of qualifying you for the Low Income Assistance Program.*
    Please type First and Last Name
55. By typing your name below, you are stating that all information listed above is true and correct under penalty of perjury under laws of California.*
    Please type First and Last Name
57. By typing your name below, you are certifying that you are not claimed on another person's income tax return.*
    Please type First and Last Name
59. Date of Application Request
    Date of Application Request
61. For More Information Please Call (909) 370-5518 or Email electricprograms@coltonca.gov.
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

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