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2. Date: *
4. Name:*
6. Account Number: *
8. Service address: *
10. Phone number: *
12. E-mail address: *
14. Statements by Email

    Check this box to receive your statements by email:

    1. I would like to receive electronic bills
16. "REQUIRED' Upload a copy of your Southern California Edison, or SoCalGas utility statement demonstrating your current participation in their CARE programs*
    To upload a document you first need to scan in the document and save on your computer. Once saved you can click the browse button to select the document to upload to your application.
18. "I Accept Terms of Conditions"*

    By clicking the "I ACCEPT" check box below, you agree that you have read and understand the Customer Assistance Programs Guidelines Terms and Conditions on the previous page.

    1. "I ACCEPT"
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20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit Submit and Print

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