PECO Universal Services - Customer Assistance Program (CAP) Application PECO CAP, P.O. Box 467429, Atlanta, GA 31146-9801

INSTRUCTIONS: Please complete the application below. Attach proof of total gross income (before taxes) for each household member including yourself, and sign your name at the X.

PLEASE COMPLETE ALL INFORMATION IN ORDER FOR THIS APPLICATION TO BE PROCESSED. (Please Print Clearly) 1. Enter your account number, home phone number, name, address, and cell phone number 2. Enter the name of all members of your household including yourself 3. Attach proof of gross household income for all members in your household including yourself 4. There are four (4) ways to submit your CAP application, see reverse for details

See back of this application for acceptable sources of income and where to submit your CAP application.

You can receive CAP application updates via text message by checking the text message "check box" next to cell phone number below. Otherwise, you will be notified by mail.

List all the people who live with you, starting with yourself. Include all adults and children. Attach proof of all income for all household members including you. Attach additional sheet, if needed.

My signature on this CAP application gives my permission to PECO or its authorized agent to: (a) check any information I give about where I live, my jobs, income, resources, and energy supplier for me or any member of my household; (b) find out about the costs of my shelter, and heating use; (c) complete any survey or reporting to a governmental agency that it may be requested to do by that agency; (d) obtain a copy of the federal income tax return for me or any member of my household. I authorize the release of limited information to approved agencies which provide other energy /weatherization assistance for which I may be eligible. I certify that the information I gave is true, correct and complete to the best of my knowledge. I understand that if I give false information, I can be denied or removed from CAP and subject to repay any CAP benefits received to date. You must sign this application to receive the CAP fixed bill amount.

If you need help with your application, please call 1-800-774-7040

** CAP Acceptable Proof of Income Documents – Last 30 days or the last 12 months of Gross Household Income, whichever most accurately reflects your average annual income. PECO may accept forms other than those listed below ** ** Please send copies only **

• Pay Stubs - Last 30 days of Gross Income (e.g., 4 weekly, 2 bi-weekly)
• Employer Verification Letter on Company Letterhead(include amount paid and frequency)

• Pension Award Letter
• Monthly Check
• Monthly Bank Statement showing direct deposit

• Workmen’s Compensation Checks Last 30 Days
• Workmen’s Compensation Award Letter
• Monthly Bank Statement Workmen’s Compensation deposits

• Veteran’s Benefit Award Letter
• Veteran’s Benefit Check – Last 30 Days
• Monthly Bank Statement showing Veteran’s Benefit direct deposit

• DPW Award Letter for Cash Benefits Only
• COMPASS Account Detail Print Out

• Domestic Relations “Financial Obligation” Form fromCourt
• Letter from person providing voluntary Child Support that is not Court Ordered (include amount paid and frequency)

• Alimony Monthly Check or Monthly Bank Statement

Social Security (SSI, SSD, Survivor Benefits, etc.)

• Social Security Award Letter for Current Year
• SSI Award Letter
• SS Disability Award Letter
• Survivor Benefit Award Letter

• Rental Lease / Cancelled Rental ChecksRental Receipt

• Unemployment Denial Letter
• Workmen’s Compensation Exhaustion of Benefit or Denial Letter
• Veteran’s Benefit Denial Letter
• DPW Benefit STOP Notice or DPW Denial Letter
• Social Security Benefits Denial Letter
• Form letter proclaiming no income – Go to peco.com/CAP or Call 1-800-774-7040 for the PECO CAP No-Income Form
• Letter From Person (i.e. Family Member) who helps you pay your bills

There are four (4) ways to submit your CAP application: 1. On-line at PECO.com/CAP 2. E-mail - PECOCAP@exeloncorp.com 3. Fax information to 1-855-358-9369 (Toll Free) (Note: you must include account number and name on every page) 4. Mail the completed application along with the required proof of income to:

PECO CAP, P.O. Box 467429, Atlanta, GA 31146-9801

If you need help with your application, please call 1-800-774-7040