PGW Customer Responsibility Program (CRP) APPLICATION / RECERTIFICATION FORM

Name

Account Number

Please Check

New ApplicationRecertification

Address

Street Address Line 2

Zip

Area Code

Phone

Name (applicant)

First NameLast Name

Social Security and Date of Birth

SSDOB

Under 18 Y/N

Y/N

Average Gross Monthly Income

Household Information (Please list all children and adults living in your home, starting with yourself)

	Last Name	First Name	Relationship	Social Security	Date of Birth	Under 18 Y/N	Average Gross Monthly Income

Household Information (Please list all children and adults living in your home, starting with yourself)

	Last Name	First Name	Relationship	Social Security	Date of Birth	Under 18 Y/N	Average Gross Monthly Income

Household Information (Please list all children and adults living in your home, starting with yourself)

	Last Name	First Name	Relationship	Social Security	Date of Birth	Under 18 Y/N	Average Gross Monthly Income

Average gross monthly inc.

(If you need to include more household members, please attach a separate sheet)

IMPORTANT: Attach copies of current income documentation for all household members listed above (e.g., all pay stubs within last 30 days, social security letter PGW will use this documentation to calculate each household member’s average gross monthly income, using year-to-date earnings, if necessary. For adults over age 18 who do not have an income, use the lines below to explain their current situation (e.g., “applied for unemployment, but not eligible”, “enrolled in high school college” Failure to provide this information when you apply may require follow up verification, which will delay processing.

For adults over age 18 who do not have an income, use the lines below to explain their current situation (e.g., “applied for unemployment, but not eligible”, “enrolled in high school college”

Additional Financial Assistance (to be completed in its entirety and signed by the person providing assistance)

If someone not living in your home provides financial assistance to you or someone else in your home, they must complete the section belowandsign where notePGW may require verification of the information stated in this section.

Name of person providing assistance

Phone

Address

Street Address Line 2

CityState

Zip

(Signature of person providing assistance)

I certify that I provide above and I understand that PGW can request verification of this information upon request.

/month in cash assistance to the CRP applicant listed

Other Assistance (Yes or No response is required)

ndicate if your household receives thefollowing types of assistance listed below, and the amount received for each (please attach documentation, such as the DPW Letter of Eligibility or a COMPASS printout). PGW does NOTincludethe dollar amount of this assistance as income when determining eligibility for CRP. The purpose for obtaining this information is to reduce the need for follow-up when determining how your household meets basic living expenses.

Food Stamps

NoYes If yes, please list amount per month

Yes If yes, please list amount per month

Food Stamps

Housing subsidy (e.g., PHA housing, voucher)NoYes If yes, please list amount per month

Yes If yes, please list amount per month

1. I agree to pay PGW the monthly CRP amount, plus $5 toward my pre-program arrears (if any), and other additional charges that apply. 2. I understand that I will receive 1/36th forgiveness of pre-program arrears only in months that I pay my total amount due on time and in full. 3. I understand that if I miss one payment, I will be in default, collection activity will begin, and my service may be terminated. 4. I agree to apply for LIHEAP and list PGW as the utility company to which I want payment sent. 5. I agree to recertify each year by submitting a CRP application with updated household information and income documentation. 6. I agree to report all changes in household size and income, even if the changes occur before my required annual recertification. 7. I agree to accept the free services of PGW’s conservation programs, if offered to me. 8. I agree to make a significant effort to conserve energy. 9. I hereby authorize PGW to verify information provided on this form through internal and third party sources, including City and State records and to obtain additional information from any source for any review. 10. I agree that if I fail to meet any of the Customer Responsibilities above, PGW may remove me from the Customer Responsibility Program.

Important Notice PUC requirements limit enrollment in CRP to customers who meet the income eligibility. PGW uses internal and third party sources, as well as standard benefit determinations made by the Social Security Administration and the Department of Public Welfare, to routinely audit and assess information and documentation provided by customers who apply for CRP. If through investigation you are found to have provided false information, you will be removed from CRP and may be required to repay the discounts and forgiveness received during the period for which you were ineligible for the program. You may also be subject to criminal prosecution for fraud. By signing below, you acknowledge that you have provided complete and correct information, have read and understand this notice, and agree to the Customer Responsibilities above.

PGW Representative

Customer Signature

Date