SDG&E ESA Customer Interest Form

Contact Information
Name on SDG&E bill*

FirstLast
Service Address*

Address Line 1

Address Line 2

CityState

Zip Code
Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
SDG&E account number (If available)
Household Information
How many people are in the household?
Please enter the total number of adults and children that live in the household
Are you (or someone in your household) enrolled in any of the following assistance programs?
YES: Please Click inside the box for all programs that apply. If not applicable, leave box blank and move on to income field in the next section.
NO: If no qualifying programs were selected, what is your annual household income? Include income from all members of the household.
Medi-Cal for Families A&BBureau of Indian Affairs General AssistanceCalFresh (food stamps) SNAPSupplemental Security Income (SSI)Woman, Infants & Children Program (WIC)Head Start Income Eligible (Tribal Only)Low-Income Home Energy Assistance Program (LIHEAP)National School Lunch Program (NSLP)CalWorks (TANF) or Tribal TANF
Total annual household income:
Home Information
OwnRent
Single Family (stand alone, duplex or triplex)Mobile HomeMulti Family (apartment or complex with 5 or more units)
One (1)Two (2)Three or More (3+)
One (1)Two (2)Three or More (3+)
YesNo
YesNo
Central A/CHeat PumpWindow UnitsPortable A/CFansNone
Central heater/furnaceHeat pumpPortable space heaterNone
One (1)Four (4)Two (2)Five (5) + or moreThree (3)
One (1)Two (2)Three or More (3+)
Stove topOvenDishwasherClothes washerClothes dryer
Before 19701970s-1980s1980s-1990s1990s-2000s2000s-2010After 2010
GasElectricBoth
YesNoI don't know
Comment or Message
By clicking submit, I give my consent to have my information provided to RHA and its contractors and to have an RHA contractor contact me regarding the Energy Savings Assistance program. I also understand that submission of this Interest Form does not guarantee qualification for the program or home upgrades and appliances.
Reply To Address
Should be Empty:

Contact Information

Household Information

Home Information