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Get PA PGW Form 10-69-4798

PHILADELPHIA GAS WORKS CUSTOMER RESPONSIBILITY PROGRAM CRP Application Form New CRP Enrollment Recertification Customer Name Street Address/Zip Account Number Social Security Number Home Phone Work/Cell Phone List everyone living in your home. Start with yourself include all children and adults. Use additional sheets if you need more space Attach copies of Social Security cards for everyone living in your home Last Name First Name M. I. Relationship Number Date of Birth 62yrs Old and above Below 18yrs Old Self Number of Total Household Members 8. List Monthly Gross Income for members listed above starting with yourself Use additional sheets if you need more space Attach copies of proof of income for everyone living in your home Income Recipient Last name First Name Relationship Type s and/or Source s Monthly Gross Income Total Gross Monthly Household Income I agree to pay PGW the total monthly payment determined by PGW through the intake process plus 5 towards my pre-program arrears back bills and any other additional charges that may apply to me CRP Restore and CRP Non-Basic Charges. 2. I agree to apply for LIHEAP when I am on PGW s CRP agreement and assign the grant to PGW* 3. I understand that if I miss one 1 payment I will be in default with the program* If I am in default with the program I understand that collection activity will begin and my service could be terminated* 4. I agree that I will recertify every year. 5. I agree to report household income changes even if they occur before it is time to recertify for CRP. 6. I agree to let PGW install an Automatic Meter Reading AMR device on my gas meter. 7. I agree to accept services from PGW s conservation programs if offered to me. per month. 10. I authorize the Philadelphia Gas Works to verify all information provided on this form including verification with City and State records. I authorize PGW to obtain consumer credit reports for purposes of verifying the above information* Customer Signature Date 10-69-4798 Reviewed by PGW Representative Date. Start with yourself include all children and adults. Use additional sheets if you need more space Attach copies of Social Security cards for everyone living in your home Last Name First Name M. I. Relationship Number Date of Birth 62yrs Old and above Below 18yrs Old Self Number of Total Household Members 8. I. Relationship Number Date of Birth 62yrs Old and above Below 18yrs Old Self Number of Total Household Members 8. List Monthly Gross Income for members listed above starting with yourself Use additional sheets if you need more space Attach copies of proof of income for everyone living in your home Income Recipient Last name First Name Relationship Type s and/or Source s Monthly Gross Income Total Gross Monthly Household Income I agree to pay PGW the total monthly payment determined by PGW through the intake process plus 5 towards my pre-program arrears back bills and any other additional charges that may apply to me CRP Restore and CRP Non-Basic Charges..

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