r h n ademark rig o ome n edof assista c , i t a need a helping hand? public assistance programs c...

Acc

ount

Num

ber

Cust

omer

Num

ber

1.

I cur

rent

ly p

artic

ipat

e in

the

follo

win

g pr

ogra

m(s

):

Sou

ther

n Ca

lifor

nia

Edis

on (C

.A.R

.E.)

S

outh

ern

Calif

orni

a G

as C

ompa

ny (C

.A.R

.E.)

S

SI

Med

i-Cal

/Med

icai

d

WIC

N

atio

nal S

choo

l Lun

ch (N

SLP)

Cal

Fres

h/SN

AP

H

ealth

y Fa

mili

es A

&B

B

urea

u of

Indi

an A

airs

Gen

eral

Ass

ista

nce

T

AN

F/Tr

ibal

TA

NF

L

IHEA

P H

ead

Star

t Inc

ome

Elig

ible

(Trib

al O

nly)

2.

Chec

k th

e to

tal n

umbe

r of p

erso

ns in

you

r hou

seho

ld.

One

(1)

Tw

o (2

) T

hree

(3)

Fou

r (4)

F

ive

(5)

Six

(6)

M

ore

than

Six

(6+)

,

N

umbe

r

Adu

lts

Child

ren

Tota

l Num

ber

3.

Writ

e th

e to

tal y

early

hou

seho

ld in

com

e fo

r all

pers

ons

in y

our h

ouse

hold

.

This

is in

com

e be

fore

ded

uctio

ns fr

om a

ll so

urce

s:

4.

Chec

k al

l sou

rces

of i

ncom

e fo

r you

r hou

seho

ld:

Wag

es

or S

alar

ies

D

isab

ility

Pay

men

ts

Cal

WO

RKs

(TA

NF/

AFD

C)

In

tere

st o

r Div

iden

ds fr

om:

R

enta

l or R

oyal

ty In

com

e

Wor

kers

Com

pens

atio

n

Cal

Fres

h/SN

AP

Sav

ings

Acc

ount

S

chol

arsh

ips,

Gra

nts,

or o

ther

S

ocia

l Sec

urity

, SSI

, SSP

C

hild

Sup

port

S

tock

s or

Bon

ds

Aid

Use

d fo

r Liv

ing

Expe

nses

P

ensi

ons

Cas

h an

d/or

Oth

er In

com

e

5.

I st

ate

that

the

info

rmat

ion

I hav

e pr

ovid

ed in

this

appl

icat

ion

is tr

ue a

nd c

orre

ct. I

agre

e to

pro

vide

proo

f of i

ncom

e if

aske

d. I

agre

e to

info

rm L

iber

ty U

tiliti

es if

I no

long

er q

ualif

y to

rece

ive

the

disc

ount

. I kn

ow th

at if

I re

ceiv

e an

y di

scou

nt w

ithou

t

qual

ifyin

g fo

r it,

I may

be

requ

ired

to p

ay b

ack

the

disc

ount

that

I re

ceiv

ed. I

unde

rsta

nd th

at L

iber

ty U

tiliti

es c

an sh

are

my

info

rmat

ion

with

oth

er

ut

ilitie

s or t

heir

agen

ts to

enr

oll m

e in

thei

r ass

istan

ce p

rogr

ams.

Sign

atur

e

P

rint N

ame

D

ate

Add

ress

City

Phon

e

$

+=

©Co

pyrig

ht a

nd tr

adem

ark

right

s re

serv

ed.

Calif

orni

a Al

tern

ate

Rate

s for

Wat

er (C

ARW

) App

licat

ion

HOW TO QUALIFY

1

MAXIMUM HOUSEHOLD INCOME(Effective June 1, 2020 to May 31, 2021)

2OR

Number of Persons in Household Total Annual Income*

1-2 3 4 5 6 7 8

For each additional household member, add $8,960* Includes current household income from

all sources before deductions.

PUBLIC ASSISTANCE PROGRAMSIf you or another person in your household receives

benefits from any of the following programs:

Medi-Cal/MedicaidHealthy Families Categories A & BWomen, Infants & Children (WIC)CalWORKS (TANF) or Tribal TANF

Head Start Income Eligible––Tribal OnlyBureau of Indian Affairs General Assistance (BIA GA)

CalFresh / SNAP (Food Stamps)National School Lunch Program (NSLP)

Low Income Home Energy Assistance Program (LIHEAP)Supplemental Security Income (SSI)

Liberty Utilities P.O. Box 7002

Downey, CA 90241

For our neighbors who may be in need of assistance, Liberty Utilities is proud to offer the California Alternate Rates for Water Program (CARW).CARW is a low-income rate assistance program that provides a monthly discount of $7.70 on the water bill to qualifying residential customers.

There are two ways to qualify for CARW:

By participating in another utilities low-income assistance program (such as CARE from the Southern California Gas Company) or receiving benefits from programs such as Medicare, Medi-Cal and more.

By providing information that house- hold income meets program guidelines.

Enrolling is quick and easy. Just complete the attached application and return it to our office either in person or by mail.

1

2

Questions about CARW?Contact Customer Service at 562-923-9671 Or visit libertyutilities.com.

$34,480$43,440$52,400$61,360$70,320$79,280$88,240

(c)2016 Liberty Utilities. All rights reserved.

www.libertyutilities.com

See if Your Household Qualifies

Need a Helping Hand?The California Alternate Rates for Water Program