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4. Account Number (if available)
6. ARE YOU THE OWNER OF THE ACCOUNT?

   1. Yes
   2. No
7. SELECT ONE:

   1. Owner Occupied
   2. Renter
8. PROPERTY TYPE:

   1. Single-Family Home
   2. Apartment
   3. Mobile Home Unit
10. Name
11. Email Address
13. Property Address
15. City
16. State
17. Zip Code
19. Phone Number
20. Fax Number
22. ELIGIBILITY REQUIREMENTS

    Please select all that apply to determine eligibility. Documents proving eligibility will be asked upon submitting a request.

    1. Health Related Issues
    2. Recipient of CalWORKs, CalFresh, Medi-Cal, Supplemental Security, Income/State Supplementary Payment Program, or California Special Supplemental Nutrition Program for Women, Infants, and Children
    3. Annual Household Income is less than 200% of Federal Poverty Level
    4. Request for Alternative Payment Arrangement
24. ADDITIONAL COMMENTS:
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field