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For current income guidelines visit aps. com/e3. Mail completed form to Arizona Public Service APS Energy Support Program E-3 P. APS ENERGY SUPPORT PROGRAM To qualify for a reduction under the APS Energy Support Program E-3 you must meet all of the following statements I am an APS residential customer and the APS bill is in my name. My household income is at or below the income level in the listing below be sure to enter your household s total gross monthly income in the box below. OF PERSONS LIVING IN HOUSEHOLD TOTAL GROSS MONTHLY INCOME Home TELEPHONE NUMBER NAME AS SHOWN ON APS BILL LAST FIRST M. I. MAILING ADDRESS NUMBER AND STREET CITY STATE ZIP CODE Permission is hereby granted to APS or a third party designated by APS to contact any sources necessary to establish the accuracy of information given by me or other information which pertains to the verification of my eligibility to receive services under the APS Energy Support Program E-3. I. MAILING ADDRESS NUMBER AND STREET CITY STATE ZIP CODE Permission is hereby granted to APS or a third party designated by APS to contact any sources necessary to establish the accuracy of information given by me or other information which pertains to the verification of my eligibility to receive services under the APS Energy Support Program E-3. Permission is also granted to a third party authorized by APS to exchange the information that I have provided. If the information provided on this form is false and used to fraudulently obtain a reduction under this program I will be required to repay the reduced amounts. My household income is at or below the income level in the listing below be sure to enter your household s total gross monthly income in the box below. Household Size Monthly Income Level 1 person 6 people 10 people For more than 10 people add 495 per person example 11 6 346. Please print the following information* INCOMPLETE INFORMATION WILL DELAY YOUR REDUCTION* The name used here to apply for the reduction MUST be the same as the name on the APS bill* PLEASE PRINT LEGIBLY APS ACCOUNT NUMBER AS SHOWN ON APS BILL MUST BE FILLED IN TOTAL NO. OF PERSONS LIVING IN HOUSEHOLD TOTAL GROSS MONTHLY INCOME Home TELEPHONE NUMBER NAME AS SHOWN ON APS BILL LAST FIRST M. Permission is also granted to a third party authorized by APS to exchange the information that I have provided* If the information provided on this form is false and used to fraudulently obtain a reduction under this program I will be required to repay the reduced amounts. Signature Today s Date NOTE Application must be signed by THE PERSON WHOSE NAME APPEARS ON THE APS BILL* Please allow 30 45 days for processing* GUIDELINES EFFECTIVE JULY 1 2012. My household income is at or below the income level in the listing below be sure to enter your household s total gross monthly income in the box below. Household Size Monthly Income Level 1 person 6 people 10 people For more than 10 people add 495 per person example 11 6 346. Household Size Monthly Income Level 1 person 6 people 10 people For more than 10 people add 495 per person example 11 6 346. Please print the following information* INCOMPLETE INFORMATION WILL DELAY YOUR REDUCTION* The name used here to apply for the reduction MUST be the same as the name on the APS bill* PLEASE PRINT LEGIBLY APS ACCOUNT NUMBER AS SHOWN ON APS BILL MUST BE FILLED IN TOTAL NO. .

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