CALIFORNIA PUBLIC UTILITIES COMMISSION DIVISION OF WATER AND AUDITS Advice Letter Cover Sheet

Transcription

1 CALIFORNIA PUBLIC UTILITIES COMMISSION DIVISION OF WATER AND AUDITS Advice Letter Cover Sheet (Date Filed / Received Stamp by CPUC) AL # Date Mailed to Service List: Requested Effective Date: Requested Tier: 954 June 25, 2012 June 30, 2012 Tier 1 Tier 2 Tier 3 Replacing AL#: Authorized by: Compliance Filing? Rate $ N/A D The public has 20 days from Date Mailed (above) to protest this advice letter. If you chose to protest or respond to the advice letter, send Protest and/or Correspondence within 20 days to: Yes No Impact Director Division of Water and Audits 505 Van Ness Ave. San Francisco, CA % N/A and if you have capability, also to: water_division@cpuc.ca.gov Your protest also must be served on the Utility (see attached advice letter for more information and grounds for protest) Company Name: CALIFORNIA AMERICAN WATER COMPANY CPUC Utility Number: WTA:_U-210W_ Address: 1033 B. AVENUE, SUITE 200 WTB WTC City, State, Zip: CORONADO, CA WTD SWR Contact Name: Phone No. Fax No. Address: Filer Edward Pressey Edward.Pressey@amwater.com Alternate Monica Na monica.na@amwater.com Description: (In this space or on the back of this form) 1. Explain justification for requested Tier Authorized in D Describe service affected and how it is affected Applies to all LIRA customers 3. Describe differences from related Advice Letters (Similar service, replacement filing) N/A (FOR CPUC USE ONLY) WTS Budget/Activity/Type Process as: Tier 1 Tier 2 Tier 3 / / 20th Day 30th Day Project Manager: Analyst: Due Date: Completion Date: Suspended on: Extended on: Resolution No.: AL/Tariff Effective Date: Rev. 03/04/08

2 4701 Beloit Drive P (916) Sacramento, CA F (916) June 25, 2012 ADVICE LETTER NO. 954 TO THE PUBLIC UTILITIES COMMISSION OF THE STATE OF CALIFORNIA California-American Water Company (California American Water) (U210W) hereby submits for review this advice letter including the following tariff sheets applicable to all of its districts which are attached hereto: C.P.U.C. Sheet No. Title of Sheet Schedule No. LW-1-LIRA Larkfield District Tariff Area PG 1 Schedule No. LW-1-LIRA Larkfield District Tariff Area PG 2 Schedule No. LW-1-LIRA Larkfield District Tariff Area PG 3 Schedule No. LW-1-LIRA Larkfield District Tariff Area PG 4 Schedule No. LW-1-LIRA Larkfield District Tariff Area PG 5 Schedule No. LW-1-LIRA Larkfield District Tariff Area PG 6 Schedule No. LW-1-LIRA Larkfield District Tariff Area PG 7 Canceling Sheet No W 6331-W 6170-W 4890-W 4891-W 4892-W 4893-W

3 C.P.U.C. Sheet No. Title of Sheet Schedule No. LW-1-LIRA Larkfield District Tariff Area PG 8 Schedule No. LW-1-LIRA Larkfield District Tariff Area PG 9 Schedule No. LW-1-LIRA Larkfield District Tariff Area PG 10 Schedule No. LA-1-LIRA Los Angeles District District Tariff PG 1 Schedule No. LA-1-LIRA Los Angeles District District Tariff PG 2 Schedule No. LA-1-LIRA Los Angeles District District Tariff PG 3 Schedule No. LA-1-LIRA Los Angeles District District Tariff PG 4 Schedule No. LA-1-LIRA Los Angeles District District Tariff PG 5 Schedule No. LA-1-LIRA Los Angeles District District Tariff PG 6 Schedule No. LA-1-LIRA Los Angeles District District Tariff PG 7 Schedule No. LA-1-LIRA Los Angeles District District Tariff PG 8 Advice Letter No. 954 June 25, 2012 Page 2 of 13 Canceling Sheet No W 6472-W 6300-W 6336-W 6337-W 6338-W 6171-W 4585-W 6157-W 6158-W 6159-W

4 C.P.U.C. Sheet No. Title of Sheet Schedule No. LA-1-LIRA Los Angeles District District Tariff PG 9 Schedule No. LA-1-LIRA Los Angeles District District Tariff PG 10 Schedule No. LA-1-LIRA Los Angeles District District Tariff PG 11 Schedule No. LA-1-LIRA Los Angeles District District Tariff PG 12 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG1 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG2 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG3 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG4 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG5 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG6 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG7 Advice Letter No. 954 June 25, 2012 Page 3 of 13 Canceling Sheet No W 6161-W 6162-W 6303-W 6421-W 6422-W 6172-W 5637-W 5638-W 5639-W 5640-W

5 C.P.U.C. Sheet No. Title of Sheet Schedule No. MO-1-LIRA Monterey County District Tariff Area PG8 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG9 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG10 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG11 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG12 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG13 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG14 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG15 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG16 Schedule No. MO-1-LIRA Monterey County District Tariff Area PG17 Advice Letter No. 954 June 25, 2012 Page 4 of 13 Canceling Sheet No W 6270-W 6396-W 6065-W 6455-W 6456-W 6457-W 6458-W 6459-W 6430-W

6 C.P.U.C. Sheet No. Title of Sheet Shedule No. MO-1A-LIRA Monterey District Tariff Area AMBLER PARK SERVICE AREA PG1 Shedule No. MO-1A-LIRA Monterey District Tariff Area AMBLER PARK SERVICE AREA PG2 Shedule No. MO-1A-LIRA Monterey District Tariff Area AMBLER PARK SERVICE AREA PG3 Shedule No. MO-1A-LIRA Monterey District Tariff Area AMBLER PARK SERVICE AREA PG4 Shedule No. MO-1A-LIRA Monterey District Tariff Area AMBLER PARK SERVICE AREA PG5 Shedule No. MO-1A-LIRA Monterey District Tariff Area AMBLER PARK SERVICE AREA PG6 Shedule No. MO-CO-1-LIRA Monterey District Tariff Area RALPH LANE SERVICE AREA PG1 Shedule No. MO-CO-1-LIRA Monterey District Tariff Area RALPH LANE SERVICE AREA PG2 Shedule No. MO-CO-1-LIRA Monterey District Tariff Area RALPH LANE SERVICE AREA PG3 Advice Letter No. 954 June 25, 2012 Page 5 of 13 Canceling Sheet No W 6173-W 6466-W 6467-W 6468-W 6317-W 6379-W 6174-W 5268-W

7 C.P.U.C. Sheet No. Title of Sheet Shedule No. MO-CO-1-LIRA Monterey District Tariff Area RALPH LANE SERVICE AREA PG4 Schedule No. SAC-1-LIRA Sacramento District Tariff Area PG1 Schedule No. SAC-1-LIRA Sacramento District Tariff Area PG2 Schedule No. SAC-1-LIRA Sacramento District Tariff Area PG3 Schedule No. SAC-1-LIRA Sacramento District Tariff Area PG4 Schedule No. SAC-1-LIRA Sacramento District Tariff Area PG5 Schedule No. SAC-1-LIRA Sacramento District Tariff Area PG6 Schedule No. SAC-1-LIRA Sacramento District Tariff Area PG7 Schedule No. SAC-1-LIRA Sacramento District Tariff Area PG8 Schedule No. SAC-2R-LIRA Sacramento District Tariff Area PG1 Advice Letter No. 954 June 25, 2012 Page 6 of 13 Canceling Sheet No W 6343-W 6344-W 6175-W 4899-W 4900-W 4901-W 4902-W 6307-W 6346-W

8 C.P.U.C. Sheet No. Title of Sheet Schedule No. SAC-2R-LIRA Sacramento District Tariff Area PG2 Schedule No. SAC-2R-LIRA Sacramento District Tariff Area PG3 Schedule No. SAC-2R-LIRA Sacramento District Tariff Area PG4 Schedule No. SAC-2R-LIRA Sacramento District Tariff Area PG5 Schedule No. SAC-2R-LIRA Sacramento District Tariff Area PG6 Schedule No. SAC-2R-LIRA Sacramento District Tariff Area PG7 Schedule No. CO-1-LIRA Coronado District Tariff Area PG1 Schedule No. CO-1-LIRA Coronado District Tariff Area PG2 Schedule No. CO-1-LIRA Coronado District Tariff Area PG3 Schedule No. CO-1-LIRA Coronado District Tariff Area PG4 Schedule No. CO-1-LIRA Coronado District Tariff Area PG5 Advice Letter No. 954 June 25, 2012 Page 7 of 13 Canceling Sheet No W 4687-W 4905-W 4906-W 4907-W 6309-W 6324-W 6325-W 6169-W 4764-W 4886-W

9 C.P.U.C. Sheet No. Title of Sheet Schedule No. CO-1-LIRA Coronado District Tariff Area PG6 Schedule No. CO-1-LIRA Coronado District Tariff Area PG7 Schedule No. CO-1-LIRA Coronado District Tariff Area PG8 Schedule No. CO-1-LIRA Coronado District Tariff Area PG9 Schedule No. V-1-LIRA Village District Tariff Area PG1 Schedule No. V-1-LIRA Village District Tariff Area PG2 Schedule No. V-1-LIRA Village District Tariff Area PG3 Schedule No. V-1-LIRA Village District Tariff Area PG4 Schedule No. V-1-LIRA Village District Tariff Area PG5 Schedule No. V-1-LIRA Village District Tariff Area PG6 Schedule No. V-1-LIRA Village District Tariff Area PG7 Advice Letter No. 954 June 25, 2012 Page 8 of 13 Canceling Sheet No W 4888-W 6080-W 6292-W 6350-W 6351-W 6177-W 4772-W 4909-W 4910-W 4911-W

10 C.P.U.C. Sheet No W 6803-W 6804-W 6805-W 6806-W 6807-W Title of Sheet Schedule No. V-1-LIRA Village District Tariff Area PG8 Schedule No. V-1-LIRA Village District Tariff Area PG9 Schedule No. CA-LIRA California American Water PG1 Schedule No. CA-LIRA (Continued) California American Water PG2 Schedule No. CA-LIRA (Continued) California American Water PG3 Schedule No. CA-LIRA (Continued) California American Water PG4 Schedule No. CA-LIRA (Continued) California American Water PG5 Schedule No. CA-LIRA (Continued) California American Water PG6 Advice Letter No. 954 June 25, 2012 Page 9 of 13 Canceling Sheet No W 6296-W NEW NEW NEW NEW NEW NEW 6808-W 6809-W 6810-W 6811-W FORMS Low Income Program Opt Out Cover Letter in English 6436-W FORMS Low Income Program Opt Out Form in English 6435-W FORMS Low Income Program Opt Out Cover Letter in Spanish 6438-W FORMS Low Income Program Opt Out Form in Spanish 6437-W

11 C.P.U.C. Sheet No W 6813-W 6814-W 6815-W 6816-W 6817-W 6818-W 6819-W Title of Sheet FORMS Low Income Program Application and Renewal Cover Letter in English FORMS Low Income Program Application and Renewal Form in English FORMS Low Income Program Application and Renewal Cover Letter in Spanish FORMS Low Income Program Application and Renewal Form in Spanish FORMS Low-Income Ratepayer Assistance Program H2O Help to Others Pamphlet Table of Contents (Continued) PG 2 Table of Contents (Continued) PG 3 Table of Contents (Continued) PG 7 Advice Letter No. 954 June 25, 2012 Page 10 of 13 Canceling Sheet No W 6439-W 6442-W 6441-W 6434-W 6796-W 6793-W 6541-W 6820-W Table of Contents PG W Purpose: This advice letter is being made to consolidate low income ratepayer assistance program tariffs into a single, statewide low income tariff; as well update the income guidelines for the year in compliance with Public Utilities Code Section Background: In D , the Commission approved the following: 6.7. Low-Income Tariff Consolidation The parties recommend that Cal-Am be allowed to file a single company-wide tariff for low-income water customers and a single tariff for low-income wastewater customers. Cal-Am states that it currently has nine separate tariffs for low-income water and all nine tariffs have the same parameters and conditions. Cal-Am asserts that consolidation will make the tariffs much easier to administer for both Cal-Am and the Commission. Cal-

12 Advice Letter No. 954 June 25, 2012 Page 11 of 13 Am s consolidated low-income tariffs will become effective five days after Cal-Am files a Tier 1 advice letter. 1 Request: This advice letter is being filed pursuant to D , which authorizes California-American Water to file an advice letter consolidating all the current low-income tariffs into a single company-wide low income tariff for water service and a single low-income tariff for wastewater service, in accordance with the settlement agreement between the Natural Resources Defense Council and California American Water adopted by D This filing is also being made to update the income limits to the LIRA Program beginning June 1, 2012 through May 31, 2013 as stated in a letter from the Energy Division on March 15, 2012 (Workpaper 3-1). Household Size CARE & Energy Savings Assistance Program (LIRA program) 1 $22,340 2 $30,260 3 $38,180 4 $46,100 5 $54,020 6 $61,940 7 $69,860 8 $77,780 Each Additional person $7,920 Tier Designation: This advice letter is being submitted pursuant to General Order No. 96-B and is designated as a Tier 1 filing. Effective Date: California American Water requests that the tariffs discussed above, be made effective June 30, The updated income eligibility requirements should be made effective June 1, Service List: In accordance with Section 4.3 of General Order No. 96-B, a copy of this advice letter is being sent to those entities listed in Exhibit A. Protest and Responses: Anyone may respond to or protest this advice letter. A response supports the filing and may contain information that proves useful to the Commission in evaluating the advice letter. A protest objects to the advice letter in whole or in part and must set forth the specific grounds on which it is based. These grounds may include the following: (1) The utility did not properly serve or give notice of the advice letter; 1 D , pp (footnote omitted).

13 Advice Letter No. 954 June 25, 2012 Page 12 of 13 (2) The relief requested in the advice letter would violate statute or Commission order, or is not authorized by statute or Commission order on which the utility relies; (3) The analysis, calculations, or data in the advice letter contain material errors or omissions; (4) The relief requested in the advice letter is pending before the Commission in a formal proceeding; or (5) The relief requested in the advice letter requires consideration in a formal hearing, or is otherwise inappropriate for the advice letter process; or (6) The relief requested in the advice letter is unjust, unreasonable, or discriminatory (provided that such a protest may not be made where it would require relitigating a prior order of the Commission.). A protest shall provide citations or proofs where available to allow staff to properly consider the protest. A response or protest must be made in writing or by electronic mail and must be received by the Water Division within 20 days of the date this advice letter is filed. The address for mailing or delivering a protest is: Tariff Unit, Water Division, 3 rd floor California Public Utilities Commission, 505 Van Ness Avenue, San Francisco, CA water_division@cpuc.ca.gov On the same date the response or protest is submitted to the Water Division, the respondent or protestant shall send a copy by mail (or ) to us, addressed to: Recipients: Mailing Address: David P. Stephenson... dave.stephenson@amwater.com Beloit Drive Director Rates & Regulatory Sacramento, CA Fax: (916) Sarah E. Leeper... Vice President Legal, Regulatory Edward Pressey... Business Performance Manager sarah.leeper@amwater.com Hayes Street San Francisco, CA Fax: (415) edward.pressey@amwater.com Beloit Drive Sacramento, CA Fax: (916)

14 Advice Letter No. 954 June 25, 2012 Page 13 of 13 Cities and counties that need Board of Supervisors or Board of Commissioners approval to protest should inform the Water Division, within the 20-day protest period, so that a late filed protest can be entertained. The informing document should include an estimate of the date the proposed protest might be voted on. If you have not received a reply to your protest within 10 business days, contact this person at (916) CALIFORNIA-AMERICAN WATER COMPANY /s/ David P. Stephenson David P. Stephenson Director - Rates & Regulatory

15 CALIFORNIA-AMERICAN WATER COMPANY Original C.P.U.C. SHEET NO W 1033 B Avenue, Suite 200 CORONADO, CA CANCELLING C.P.U.C. SHEET NO. NEW Schedule No. CA-LIRA California American Water APPLICABILITY (N) Applicable to all water furnished on a metered basis. TERRITORY RATES All territories served by California American Water Company Larkfield District Surcredit Per Month Low Income Discount $14.50 Los Angeles County District Low Income Discount Baldwin Hills Area $8.50 Low Income Discount Duarte Area $8.50 Low Income Discount San Marino Area $10.50 Monterey County District Low Income Discount 1-4 Individuals $10.00 Low Income Discount 5-8 Individuals $15.00 Low Income Discount over 8 Individuals $20.00 Low Income Discount Ambler Park Area $13.00 Low Income Discount Ralph Lane Area $11.50 Low Income Discount Toro Area $23.00 Sacramento District Low Income Discount Metered Customers $9.00 Low Income Discount Flat-Rate Customers $9.00 San Diego County District Low Income Discount $6.00 Ventura County District Low Income Discount $14.00 The Low-income discount is a fixed monthly surcredit applicable to qualifying low-income residential customers. (N) (Continued) (TO BE INSERTED BY UTILITY) ISSUED BY (TO BE INSERTED BY C.P.U.C.) ADVICE LETTER NO. 954 D. P. STEPHENSON DATE FILED NAME EFFECTIVE DECISION NO. D DIRECTOR Rates & Regulatory RESOLUTION TITLE

16 CALIFORNIA-AMERICAN WATER COMPANY Original C.P.U.C. SHEET NO W 1033 B Avenue, Suite 200 CORONADO, CA CANCELLING C.P.U.C. SHEET NO. NEW Schedule No.CA-LIRA (Continued) California American Water SPECIAL CONDITIONS APPLICABLE TO LOW INCOME (N) 1. Low Income Ratepayer Assistance Program (LIRA): As reflected in this tariff, qualifying customers receive a surcredit, as noted above, per month per qualifying residential customer. Customers must apply with the Company for acceptance into the low income program. Qualification criteria are outlined below. This program is also known as the H2O Help to Others Program. a. LIRA Household: A LIRA Household is a household where the total gross income from all sources, including total income from all persons living full-time in the household, is less than shown on the table below based on the number of persons in the household. Total gross income shall include both taxable and non-taxable income. Persons who are claimed as a dependent on another person s income tax return are not eligible for this program. The California American Water bill must be in the customer s name. Household Size CARE & Energy Savings Assistance Program (LIRA program) 1 $22,340 2 $30,260 3 $38,180 4 $46,100 5 $54,020 6 $61,940 7 $69,860 8 $77,780 Each Additional person $7,920 (N) (Continued) (TO BE INSERTED BY UTILITY) ISSUED BY (TO BE INSERTED BY C.P.U.C.) ADVICE LETTER NO. 954 D. P. STEPHENSON DATE FILED NAME EFFECTIVE DECISION NO. D DIRECTOR Rates & Regulatory RESOLUTION TITLE

17 CALIFORNIA-AMERICAN WATER COMPANY Original C.P.U.C. SHEET NO W 1033 B Avenue, Suite 200 CORONADO, CA CANCELLING C.P.U.C. SHEET NO. NEW Schedule No. CA-LIRA (Continued) California American Water SPECIAL CONDITIONS APPLIACABLE TO LOW INCOME (Continued): (N) 1. Low Income Ratepayer Assistance Program (LIRA) (Continued): b. Application and Eligibility Declaration: An application and eligibility declaration on a form authorized by the Commission is required for each request for service under this schedule. Renewal of a customer s eligibility declaration will be required every two years and may be required on an annual basis. Customers are only eligible to receive service under this rate schedule at one residential location at any one time, and the rate applies only to the customer s permanent primary residence. This schedule is not applicable where, in the opinion of the Company, either the accommodation or the occupancy is transitory. Customers may self certify and may be requested to present documentation verifying participation in a low income assistance program. c. Commencement of Rate: Eligible customers shall be billed on this schedule commencing no later than one billing period after receipt and approval of the customer s application by the Company. d. Verification: Information provided by the applicant is subject to verification by the Company. Refusal or failure of a customer to provide documentation of eligibility acceptable to the Company, upon the request of the Company, shall result in removal from this rate schedule. e. Notice from Customer: It is the customer s responsibility to notify the Company if there is a change in the customer s eligibility status. Notification should be made within 30 days of the customer s change in eligibility. f. Customers may be re-billed for periods of ineligibility under the applicable rate schedule. (N) (Continued) (TO BE INSERTED BY UTILITY) ISSUED BY (TO BE INSERTED BY C.P.U.C.) ADVICE LETTER NO. 954 D. P. STEPHENSON DATE FILED NAME EFFECTIVE DECISION NO. D DIRECTOR Rates & Regulatory RESOLUTION TITLE

18 CALIFORNIA-AMERICAN WATER COMPANY Original C.P.U.C. SHEET NO W 1033 B Avenue, Suite 200 CORONADO, CA CANCELLING C.P.U.C. SHEET NO. NEW Schedule No. CA-LIRA (Continued) California American Water SPECIAL CONDITIONS APPLICABLE TO LOW INCOME (Continued): (N) 2. Low Income Ratepayer Assistance Program (LIRA) for Migrant Farm Worker Housing Centers (MFHC): Consistent with Assembly Bill (AB) 868, signed on September 21, 2004, and with California Public Utilities Commission Decision No , the low-income discount shall be offered to nonprofit farm worker housing centers, including those not managed by the Office of Migrant Services (OMS). Qualifying facilities receive a surcredit equal to the applicable Low Income monthly discount in the service area per qualifying housing unit. Customers must apply with the Company for acceptance into the low income program. Qualification criteria are outlined below. This program is also known as the H2O Help to Others Program. a. LIRA for MFWHC: An MFWHC applying for acceptance into the program must meet the requirements listed below; 1. The facility must provide pursuant to section of the Health and Safety Code or meet the definition in Subdivision (b) of Section of the Labor Code and have an exemption from local property taxes pursuant to Subdivision (g) of Section 214 of the Revenue and Taxation Code. 2. The facility must provide a copy of current contract with the Office of Migrant Services, or a copy of tax-exempt documentation. b. Application and Eligibility Declaration: An application and eligibility declaration on a form authorized by the Commission is required for each request for service under this schedule. Renewal of a customer s eligibility declaration will be required every two years and may be required on an annual basis. Customers are only eligible to receive service under this rate schedule at one residential location at any one time, and the rate applies only to the customer s permanent primary residence. This schedule is not applicable where, in the opinion of the Company, either the accommodation or the occupancy is transitory. Customers may self certify and may be requested to present documentation verifying participation in a low-income assistance program. c. Commencement of Rate: Eligible customers shall be billed on this schedule commencing no later than one billing period after receipt and approval of the customer s application by the Company. d. Verification: Information provided by the applicant is subject to verification by the Company. Refusal or failure of a customer to provide documentation of eligibility acceptable to the Company, upon the request of the Company, shall result in removal from this rate schedule. e. Notice from Customer: It is the customer s responsibility to notify the Company if there is a change in the customer s eligibility status. Notification should be made within 30 days of the customer s change in eligibility. f. Customers may be re-billed for periods of ineligibility under the applicable rate schedule. (N) (Continued) (TO BE INSERTED BY UTILITY) ISSUED BY (TO BE INSERTED BY C.P.U.C.) ADVICE LETTER NO. 954 D. P. STEPHENSON DATE FILED NAME EFFECTIVE DECISION NO. D DIRECTOR Rates & Regulatory RESOLUTION TITLE

19 CALIFORNIA-AMERICAN WATER COMPANY Original C.P.U.C. SHEET NO W 1033 B Avenue, Suite 200 CORONADO, CA CANCELLING Revised C.P.U.C. SHEET NO. NEW Schedule No. CA-LIRA (Continued) California American Water SPECIAL CONDITIONS APPLICABLE TO LOW INCOME (Continued): (N) 3. Low-Income Ratepayer Assistance Program (LIRA) for Nonprofit Group Living Facilities: Group living facilities, homeless shelters, hospices and women s shelters may be eligible for the low-income discount. Qualifying facilities receive a surcredit equal to the applicable Low-Income monthly discount in the service area per qualifying housing unit. Customers must apply with the Company for acceptance into the low income program. Qualification criteria are outlined below. This program is also known as the H2O Help to Others Program. a. LIRA for Nonprofit Group Living Facilities: A nonprofit group living facility applying for acceptance into the program must meet the following requirements; 1. The organization operating the facility must provide a copy of the 501(c) (3) document certifying tax-exempt status. 2. All California American Water accounts must be in the name of the organization holding the tax-exempt status. 3. All of the residents or clients (including family units) occupying the facility at any given time must individually meet current income eligibility requirements as shown in Section 1 of this tariff schedule. b. Facilities that are not eligible for the program: 1. Nonprofit facilities providing social services only. 2. Group living facilities providing no other service than a place to live. 3. Government owned or operated facilities. 4. Government-subsidized facilities providing lodging only. c. Additional requirements: Group living facilities must provide special-needs social services such as meals or rehabilitation, and may have satellite facilities in the name of one licensed organization that meet The same requirements as the main facility. Group living facilities include transitional housing such As drug rehabilitation centers or halfway houses, short-or long-term care facilities, group homes for the physically or mentally Challenged and other nonprofit group living facilities. (N) (Continued) (TO BE INSERTED BY UTILITY) ISSUED BY (TO BE INSERTED BY C.P.U.C.) ADVICE LETTER NO. 954 D. P. STEPHENSON DATE FILED NAME EFFECTIVE DECISION NO. D DIRECTOR Rates & Regulatory RESOLUTION TITLE

20 CALIFORNIA-AMERICAN WATER COMPANY Original C.P.U.C. SHEET NO W 1033 B Avenue, Suite 200 CORONADO, CA CANCELLING C.P.U.C. SHEET NO. NEW Schedule No.CA-LIRA (Continued) California American Water SPECIAL CONDITIONS APPLICABLE TO LOW INCOME (Continued): (N) 3. Low-Income Ratepayer Assistance Program (LIRA) for Nonprofit Group Living Facilities: (Continued) c. Additional requirements: (Continued) Homeless shelters, hospices and women s shelters must provide lodging as the primary Function, must be open for operation with at least six beds for a minimum of 180 days and/or nights per year and may also have satellite facilities in the name of one licensed organization that meet the same requirements as the main facility. Separate applications must be filed for each type of facility (a homeless shelter, a women s shelter, a hospice or group living facility), even if they are under one licensed organization. d. Application and Eligibility Declaration: An application and eligibility declaration on a form authorized by the Commission is required for each request for service under this schedule. Renewal of a customer s eligibility declaration will be required every two years and may be required on an annual basis. Customers are only eligible to receive service under this rate schedule at one residential location at any one time, and the rate applies only to the customer s permanent primary residence. This schedule is not applicable where, in the opinion of the Company, either the accommodation or the occupancy is transitory. Customers may self certify and may be requested to present documentation verifying participation in a low-income assistance program. e. Commencement of Rate: Eligible customers shall be billed on this schedule commencing no later than one billing period after receipt and approval of the customer s application by the Company. f. Verification: Information provided by the applicant is subject to verification by the Company. Refusal or failure of a customer to provide documentation of eligibility acceptable to the Company, upon the request of the Company, shall result in removal from this rate schedule. g. Notice from Customer: It is the customer s responsibility to notify the Company if there is a change in the customer s eligibility status. Notification should be made within 30 days of the customer s change in eligibility. h. Customers may be re-billed for periods of ineligibility under the applicable rate schedule. (N) (TO BE INSERTED BY UTILITY) ISSUED BY (TO BE INSERTED BY C.P.U.C.) ADVICE LETTER NO. 954 D. P. STEPHENSON DATE FILED NAME EFFECTIVE DECISION NO. D DIRECTOR Rates & Regulation RESOLUTION TITLE

21 CALIFORNIA-AMERICAN WATER COMPANY Revised C.P.U.C. SHEET NO W 1033 B Avenue, Suite 200 CORONADO, CA CANCELLING Original C.P.U.C. SHEET NO W Low Income Program Opt Out Cover Letter in English See Attachment Form (TO BE INSERTED BY UTILITY) ISSUED BY (TO BE INSERTED BY C.P.U.C.) ADVICE LETTER NO. 954 D. P. STEPHENSON DATE FILED NAME EFFECTIVE DECISION NO. D DIRECTOR Rates & Regulation RESOLUTION TITLE

22 California American Water P.O. Box 578, AltonIL /31/2012 Longbotham Karen & 664 Flaming Star Ave Thousand Oaks, CA Account Number: Premise Number: Flaming Star Av, Thousand Oaks CA Enrollment in H2O - Help to Others Low Income Assistance Program Dear California American Water Customer: If you want to lower your monthly water bill - you don't have to do a thing. Because you are currently qualified under the California Alternate Rate Energy (CARE) program and are receiving rate assistance from your electric and gas utility you will automatically receive a discount on your water bill. Why would you receive a discount on your water bill? The H2O - Help to Others low income assistance program provides discounts toward the water bills of eligible low-income households who meet the income qualifications and other criteria listed on the attached form. What if you DON'T want to receive the discount or no longer qualify? If you do not want the discount or no longer meet the qualifications, please fill out the top portion of the attached form, mark the "opt out" box and return to us. For more information on the program or for other questions please visit our website or call us at Sincerely, California American Water CAH2OEE_V

23 CALIFORNIA-AMERICAN WATER COMPANY Revised C.P.U.C. SHEET NO W 1033 B Avenue, Suite 200 CORONADO, CA CANCELLING Original C.P.U.C. SHEET NO W Low Income Program Opt Out Form in English See Attachment Form (TO BE INSERTED BY UTILITY) ISSUED BY (TO BE INSERTED BY C.P.U.C.) ADVICE LETTER NO. 954 D. P. STEPHENSON DATE FILED NAME EFFECTIVE DECISION NO. D DIRECTOR Rates & Regulation RESOLUTION TITLE

24 California American Water H2O Help to Others Program (H2O) Low Income Assistance Program CALIFORNIA AMERICAN WATER CUSTOMER INFORMATION: (please type or print) Customer Account Number Name Telephone ( ) As it appears on your bill Home Address City CA Zip Code Do NOT use a P.O. Box Mailing Address City CA Zip Code If different from above address OPT OUT - I do not wish to be enrolled in the Low Income Assistance Program PROGRAM INFORMATION MAXIMUM HOUSEHOLD INCOME: (effective June 1, 2012 to May 31, 2013) Your Household's gross annual income may not exceed these CARE income guidelines. Household Size Each Additional Person Total Combined Annual Income $ 22,340 $ 30,260 $ 38,180 $ 46,100 $ 54,020 $ 61,940 $ 69,860 $ 77,780 $ 7,920 PUBLIC ASSISTANCE PROGRAM ELIGIBILITY: Medicaid/Medi-Cal (under age 65) Medicaid/Medi-Cal (age 65 and over) Supplemental Security Income (SSI) National School Lunch Program (NSLP) Women, Infants and Children (WIC) Healthy Families A & B CalWORKs (TANF) or Tribal TANF Low Income Home Energy Assistance Program (LIHEAP) CalFresh/SNAP (Food Stamps) Bureau of Indian Affairs General Assistance Head Start Income Eligible (Tribal Only) Wages and/or Profits from SelfEmployment Rental or Royalty Income Unemployment Benefits Scholarships, Grants or other aid for living expenses Insurance or Legal Settlements Spousal or Child Support Cash and/or Other Income HOUSEHOLD INCOME ELIGIBILITY: Pensions Social Security SSP or SSDI Interests/Dividends from: Savings, Stocks, Bonds, or Retirement Accounts Disability or Workers Compensation Payments For Questions Call: Mail Completed Application to: California American Water, 8657 Grand Avenue, Rosemead, CA CAH2OEE_V

25 CALIFORNIA-AMERICAN WATER COMPANY Revised C.P.U.C. SHEET NO W 1033 B Avenue, Suite 200 CORONADO, CA CANCELLING Original C.P.U.C. SHEET NO W Low Income Program Opt Out Cover Letter in Spanish See Attachment Form (TO BE INSERTED BY UTILITY) ISSUED BY (TO BE INSERTED BY C.P.U.C.) ADVICE LETTER NO. 954 D. P. STEPHENSON DATE FILED NAME EFFECTIVE DECISION NO. D DIRECTOR Rates & Regulation RESOLUTION TITLE

26 California American Water P.O. Box 578, AltonIL /31/2012 Longbotham Karen & 664 Flaming Star Ave Thousand Oaks, CA Número de cuenta: Premisa número: Flaming Star Av, Thousand Oaks CA Inscripción en H2O - Ayuda para Otros, Programa de asistencia para familias con recursos limitados Estimado Cliente de California American Water: Si desea reducir su factura mensual de agua - no tiene que hacer nada. Dado que usted está actualmente calificado en virtud del programa California Alternate Rate Energy (CARE) y está recibiendo una tarifa preferencial de ayuda que le brinda su compañía de electricidad y gas, usted recibirá automáticamente un descuento en su factura de agua. Por qué recibiría usted un descuento en su factura de agua? El programa H2O - Help to Others, de asistencia para familias con recursos limitados ofrece descuentos para el pago de facturas de agua de aquellos grupos familiares elegibles con recursos limitados que cumplen las condiciones de ingreso y otros criterios enumerados en el formulario de adjunto. Qué hacer si NO desea recibir el descuento o ya no califica para ello? Si no desea recibir el descuento o si ya no califica para recibirlo, llene la parte superior del formulario adjunto, marque la casilla opt out (opción de exclusión) y devuélvanos el formulario. Si desea más información sobre el programa o si tiene otras preguntas visite nuestro sitio Web o llámenos al Atentamente, California American Water CAH2OES_V

27 CALIFORNIA-AMERICAN WATER COMPANY Revised C.P.U.C. SHEET NO W 1033 B Avenue, Suite 200 CORONADO, CA CANCELLING Original C.P.U.C. SHEET NO W Low Income Program Opt Out Form in Spanish See Attachment Form (TO BE INSERTED BY UTILITY) ISSUED BY (TO BE INSERTED BY C.P.U.C.) ADVICE LETTER NO. 954 D. P. STEPHENSON DATE FILED NAME EFFECTIVE DECISION NO. D DIRECTOR Rates & Regulation RESOLUTION TITLE

28 California American Water SOLICITUD para el programa H2O Help to Others de asistencia para personas con bajos ingresos INFORMACIÓN DEL CLIENTE DE CALIFORNIA AMERICAN WATER: (imprima o escriba en letra de imprenta) Número de cuenta del cliente Nombre telefónico ( ) Como aparece en su factura Dirección Particular Ciudad Código Postal de CA NO utilice un apartado postal (PO Box) Dirección de correo Ciudad Código Postal de CA Si es diferente de la dirección que figura arriba NO DESEO PARTICIPAR - No quiero ser inscrito en el Programa de Asistencia INFORMACIÓN PARA LA CERTIFICACIÓN INGRESO FAMILIAR MÁXIMO: (vigentes desde el 1 de junio de 2012 hasta el 31 de mayo de 2013) Su ingreso anual bruto familiar no debe superar estas pautas de ingresos de CARE. Cantidad de personas en el grupo familiar Cada persona adicional Ingreso anual combinado total $ 22,340 $ 30,260 $ 38,180 $ 46,100 $ 54,020 $ 61,940 $ 69,860 $ 77,780 $ 7,920 ELEGIBILIDAD PARA EL PROGRAMA DE ASISTENCIA PÚBLICA: Medicaid/Medi-Cal (menor de 65 años de edad) Medicaid/Medi-Cal (de 65 años de edad y mayores) Programa federal de seguridad de ingreso suplementario Programa para mujeres, lactantes y niños (WIC) Programas Healthy Families A y B (Familias Saludables) CalWORKs (TANF) o TANF Tribal Programa de ayuda para energía para hogares con recursos limitados CalFresh/SNAP(sellos para alimentos) Ayuda General de la Oficina de Asuntos Indígenas Programa nacional de almuerzos escolares Elegibilidad de ingresos para el programa Head Start (Tribal solamente) Salarios o ganancias de empleo por cuenta propia Ingreso por alquileres o regalías Beneficios por desempleo Pagos por incapacidad o de Compensación Laboral Becas escolares, subvenciones u otras ayudas para gastos de vida ELEGIBILIDAD DEL INGRESO FAMILIAR: Pensiones Seguro Social SSP ó SSDI Intereses/dividendos de: ahorros, acciones, bonos, o cuentas de jubilación indemnizaciones de seguros o judiciales Cuotas de manutención de cónyuge o de hijos Efectivo u otros ingresos Si tiene alguna pregunta llame al: Envie la solicitud completa a: California American Water, 8657 Grand Avenue, Rosemead, CA CAH2OES_V

29 CALIFORNIA-AMERICAN WATER COMPANY Revised C.P.U.C. SHEET NO W 1033 B Avenue, Suite 200 CORONADO, CA CANCELLING Original C.P.U.C. SHEET NO W Low Income Program Application and Renewal Cover Letter in English See Attachment Form (TO BE INSERTED BY UTILITY) ISSUED BY (TO BE INSERTED BY C.P.U.C.) ADVICE LETTER NO. 954 D. P. STEPHENSON DATE FILED NAME EFFECTIVE DECISION NO. D DIRECTOR Rates & Regulation RESOLUTION TITLE

30 California American Water P.O. Box 578, AltonIL /31/2012 Longbotham Karen & 664 Flaming Star Ave Thousand Oaks, CA Account Number: Premise Number: Flaming Star Av, Thousand Oaks CA Re-enrollment in H2O - Help to Others Low Income Assistance Program Dear California American Water Customer: California American Water is pleased to offer customers on fixed incomes or facing financial difficulties a discount on their water bill through our H2O- Help to Others program. It has come to our attention that you are currently enrolled in the H2O - Help to Others Low Income assistance program but we do not have current enrollment information on file. Please fill out the attached application within 30 days. If you do not wish to be enrolled in the program you do not need to fill out the form or take further action. For more information on the program or for other questions please visit our website or call us at Sincerely, California American Water CAH2ORE_V

31 CALIFORNIA-AMERICAN WATER COMPANY Revised C.P.U.C. SHEET NO W 1033 B Avenue, Suite 200 CORONADO, CA CANCELLING Original C.P.U.C. SHEET NO W Low Income Program Application and Renewal form in English See Attachment Form (TO BE INSERTED BY UTILITY) ISSUED BY (TO BE INSERTED BY C.P.U.C.) ADVICE LETTER NO. 954 D. P. STEPHENSON DATE FILED NAME EFFECTIVE DECISION NO. D DIRECTOR Rates & Regulation RESOLUTION TITLE

32 California American Water H2O Help to Others Program (H2O) Low Income Assistance Program CALIFORNIA AMERICAN WATER CUSTOMER INFORMATION: (please type or print) Customer Account Number Name Telephone ( ) As it appears on your bill Home Address City CA Zip Code Do NOT use a P.O. Box Mailing Address City CA Zip Code If different from above address Number of people living in your household Adults + Children = Total + = CERTIFICATION INFORMATION MAXIMUM HOUSEHOLD INCOME: (effective June 1, 2012 to May 31, 2013) Your Household's gross annual income may not exceed these CARE income guidelines. Household Size Each Additional Person Total Combined Annual Income $ 22,340 $ 30,260 $ 38,180 $ 46,100 $ 54,020 $ 61,940 $ 69,860 $ 77,780 $ 7,920 PUBLIC ASSISTANCE PROGRAM ELIGIBILITY: CHECK all programs you or someone in your household participate in. Medicaid/Medi-Cal (under age 65) Women, Infants and Children (WIC) Medicaid/Medi-Cal (age 65 and over) Healthy Families A & B Supplemental Security Income (SSI) CalWORKs (TANF) or Tribal TANF National School Lunch Program Low Income Home Energy Assistance (NSLP) Program (LIHEAP) CalFresh/SNAP (Food Stamps) Bureau of Indian Affairs General Assistance Head Start Income Eligible (Tribal Only) HOUSEHOLD INCOME ELIGIBILITY: CHECK all sources of household income. Pensions Social Security SSP or SSDI Interests/Dividends from: Savings, Stocks, Bonds, or Retirement Accounts Scholarships, Grants or other aid for living expenses Insurance or Legal Settlements Spousal or Child Support Cash and/or Other Income Wages and/or Profits from SelfEmployment Rental or Royalty Income Unemployment Benefits Disability or Workers Compensation Payments TOTAL ANNUAL HOUSEOLD INCOME: $, DECLARATION: (please read carefully and sign below) I state that the information I have provided in this application is true and correct. I agree to provide proof of income if asked. I agree to inform California American Water if I no longer qualify to receive the discount. I understand that if I receive the discount without qualifying for it, I may be required to pay back the discount I received. I understand that California American Water can share my information with other utilities or their agents to enroll me in their assistance programs. X California American Water Customer Signature fill in circle if guardian or power of attorney Date For Questions Call: Mail Completed Application to: California American Water, 8657 Grand Avenue, Rosemead, CA CAH2ORE_V

33 CALIFORNIA-AMERICAN WATER COMPANY Revised C.P.U.C. SHEET NO W 1033 B Avenue, Suite 200 CORONADO, CA CANCELLING Original C.P.U.C. SHEET NO W Low Income Program Application and Renewal Cover Letter in Spanish See Attachment Form (TO BE INSERTED BY UTILITY) ISSUED BY (TO BE INSERTED BY C.P.U.C.) ADVICE LETTER NO. 954 D. P. STEPHENSON DATE FILED NAME EFFECTIVE DECISION NO. D DIRECTOR Rates & Regulation RESOLUTION TITLE

34 California American Water P.O. Box 578, AltonIL /31/2012 Longbotham Karen & 664 Flaming Star Ave Thousand Oaks, CA Número de cuenta: Premisa número: Flaming Star Av, Thousand Oaks CA Re-inscripción en H2O - Ayuda para Otros, Programa de asistencia para familias con recursos limitados Estimado Cliente de California American Water California American Water tiene el agrado de ofrecer a sus clientes con ingresos fijos o con dificultades financieras un descuento en sus facturas de servicio de agua a través de nuestro programa H2O - Ayuda para otros. Es de nuestro conocimiento que usted está inscrito actualmente en el programa de asistencia para familias con recursos limitados H2O - Ayuda para otros, pero no tenemos información de inscripción actualizada en nuestros registros. Atentamente le solicitamos llenar la solicitud adjunta en un plazo no mayor de 30 días. Si no desea inscribirse en el programa, no es necesario que llene el formulario ni que realice acciones adicionales. Si desea más información acerca del programa o si tiene otras preguntas visite nuestro sitio Web o llámenos al Atentamente, California American Water CAH2ORS_V

35 CALIFORNIA-AMERICAN WATER COMPANY Revised C.P.U.C. SHEET NO W 1033 B Avenue, Suite 200 CORONADO, CA CANCELLING Original C.P.U.C. SHEET NO W Low Income Program Application and Renewal Form in Spanish See Attachment Form (TO BE INSERTED BY UTILITY) ISSUED BY (TO BE INSERTED BY C.P.U.C.) ADVICE LETTER NO. 954 D. P. STEPHENSON DATE FILED NAME EFFECTIVE DECISION NO. D DIRECTOR Rates & Regulation RESOLUTION TITLE

36 California American Water SOLICITUD para el programa H2O Help to Others de asistencia para personas con bajos ingresos INFORMACIÓN DEL CLIENTE DE CALIFORNIA AMERICAN WATER: (imprima o escriba en letra de imprenta) Número de cuenta del cliente Nombre telefónico ( ) Como aparece en su factura Dirección Particular Ciudad Código Postal de CA NO utilice un apartado postal (PO Box) Dirección de correo Ciudad Código Postal de CA Si es diferente de la dirección que figura arriba Cantidad de personas que viven en su hogar Adultos + Niños = Total + = INFORMACIÓN PARA LA CERTIFICACIÓN INGRESO FAMILIAR MÁXIMO: (vigentes desde el 1 de junio de 2012 hasta el 31 de mayo de 2013) Su ingreso anual bruto familiar no debe superar estas pautas de ingresos de CARE. Cantidad de personas en el grupo familiar Ingreso anual combinado total 1 $ 22,340 2 $ 30,260 3 $ 38,180 4 $ 46,100 5 $ 54,020 6 $ 61,940 7 $ 69,860 8 $ 77,780 Ingreso anual combinado total $ 7,920 ELEGIBILIDAD PARA EL PROGRAMA DE ASISTENCIA PÚBLICA: MARQUE todos los programas en los que usted o alguien en su grupo familiar participan. Medicaid/Medi-Cal Programa para mujeres, CalFresh/SNAP(sellos para alimentos) (menor de 65 años de edad) lactantes y niños (WIC) Ayuda General de la Oficina de Medicaid/Medi-Cal Programas Healthy Families A y B Asuntos Indígenas (de 65 años de edad y mayores) (Familias Saludables) Programa nacional de almuerzos Programa federal de seguridad de CalWORKs (TANF) o TANF Tribal escolares ingreso suplementario Programa de ayuda para energía para Elegibilidad de ingresos para el hogares con recursos limitados programa Head Start (Tribal solamente) ELEGIBILIDAD DEL INGRESO FAMILIAR: MARQUE todas las fuentes de ingreso familiar. Pensiones Salarios o ganancias de Becas escolares, subvenciones u Seguro Social empleo por cuenta propia otras ayudas para gastos de vida indemnizaciones de seguros o judiciales SSP ó SSDI Ingreso por alquileres o regalías Intereses/dividendos de: Beneficios por desempleo Cuotas de manutención de ahorros, acciones, bonos, o Pagos por incapacidad o de cónyuge o de hijos cuentas de jubilación Compensación Laboral Efectivo u otros ingresos INGRESO FAMILIAR ANUAL TOTAL: $, DECLARACIÓN: (lea cuidadosamente y firme al pie) Yo afirmo que la información que he suministrado en esta solicitud es verdadera y correcta. Acuerdo presentar comprobantes de ingresos si se me solicita. Acuerdo informar a California American Water si dejo de calificar para recibir descuentos. Entiendo que si recibo el descuento sin ser elegible para ello, puedo estar obligado a devolver el monto de descuento que haya recibido. Entiendo que California American Water puede compartir mi información con otras compañías de servicios públicos o sus agentes para mi inscripción en sus programas de ayuda. X Firma del cliente de California American Water rellene el círculo si es tutor o posee un poder legal Fecha Si tiene alguna pregunta llame al: Envie la solicitud completa a: California American Water, 8657 Grand Avenue, Rosemead, CA CAH2ORS_V

37 CALIFORNIA-AMERICAN WATER COMPANY Revised C.P.U.C. SHEET NO W 1033 B Avenue, Suite 200 CORONADO, CA CANCELLING Original C.P.U.C. SHEET NO W H 2 O Help to Others Program TM See Attachment Form Pamphlet (TO BE INSERTED BY UTILITY) ISSUED BY (TO BE INSERTED BY C.P.U.C.) ADVICE LETTER NO. 954 D. P. STEPHENSON DATE FILED NAME EFFECTIVE DECISION NO. D DIRECTOR Rates & Regulation RESOLUTION TITLE

38 H 2O Help to Others Program TO QUALIFY FOR H O 2 You must be an individually metered or flat-rate residential customer. The California American Water bill must be in your name. You may not be claimed as a dependent on another person s tax return. You must reapply each time you change your personal residence. You must renew your application every two years, or sooner, if requested. Your total annual income cannot exceed that on the chart to the right. Total income means the total income of ALL persons living full-time in your home as reported on Federal Income Tax Form California American Water must be notified within 30 days if you become ineligible for the H 2 O program. Low Income Assistance Program INCOME GUIDELINES Number of Persons in Household (Effective June 1, 2012 to May 31, 2013) Total Combined Annual Income 1 $ 22,340 2 $ 30,260 3 $ 38,180 4 $ 46,100 5 $ 54,020 6 $ 61,940 7 $ 69,860 8 $ 77,780 Each Additional Person $ 7,920 For households with more than eight persons, add $7,920 annually for each additional person residing in the household. For assistance, call (888) , or visit See H 2 O application on the reverse side

39 APPLICATION: H 2O Help to Others Program (H 2O) Low Income Assistance Program Mail Completed Application to: California American Water, 8657 Grand Avenue, Rosemead, CA Please fill out the form below and attach the following: 1. California American Water bill. CALIFORNIA AMERICAN WATER CUSTOMER INFORMATION: (please type or print) Customer Account Number Have you applied/enrolled in this program in the past? Yes No Name As it appears on your bill Home Address City CA Zip Code Do NOT use a P.O. Box Mailing Address City CA Zip Code If different from above address Daytime Telephone Number Please include Area Code Number of people living in your household + = Adults Children Total MAXIMUM HOUSEHOLD INCOME: (effective June 1, 2012 to May 31, 2013) Your Household s gross annual income may not exceed these CARE income guidelines. Number of Persons in Household Each Additional Person Total Combined $22,340 $30,260 $38,180 $46,100 $54,020 $61,940 $69,860 $77,780 $7,920 Annual Incomes For households with more than eight persons, add $7,920 annually for each additional person residing in the household. PUBLIC ASSISTANCE PROGRAM ELIGIBILITY (CHECK all programs you or someone in your household participate in) Medicaid/Medi-Cal (under age 65) Medicaid/Medi-Cal (age 65 and over) Supplemental Security Income (SSI) National School Lunch Program (NSLP) HOUSEHOLD INCOME ELIGIBILITY (CHECK all sources of household income) Pensions Social Security SSP or SSDI Interests/Dividends from: Savings, Stocks, Bonds, or Retirement Accounts Women, Infants and Children (WIC) Healthy Families A & B CalWORKs (TANF) or Tribal TANF Low Income Home Energy Assistance Program (LIHEAP) Wages and/or Profits from Self-Employment Rental or Royalty Income Unemployment Benefits Disability or Workers Compensation Payments CalFresh/SNAP (Food Stamps) Bureau of Indian Affairs General Assistance Head Start Income Eligible (Tribal Only) Scholarships, Grants or other aid for living expenses Insurance or Legal Settlements Spousal or Child Support Cash and/or Other Income Total Annual Household Income: $, DECLARATION: (please read carefully and sign below) I state that the information I have provided in this application is true and correct. I agree to provide proof of income if asked. I agree to inform California American Water if I no longer qualify to receive the discount. I understand that if I receive the discount without qualifying for it, I may be required to pay back the discount I received. I understand that California American Water can share my information with other utilities or their agents to enroll me in their assistance programs. X California American Water Customer Signature fill in circle if guardian or power of attorney Date For Questions Call: (888)