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Get CA C0185 - Los Angeles 2021-2022

If you have any questions regarding this application form please call the Utility Tax Exemption Unit 213 978-3050/ TTY 213 978-1532. CITY OF LOS ANGELES OFFICE OF FINANCE UTILITY USER S TAX EXEMPTION/ELECTRIC WATER LIFELINE RATE APPLICATION Los Angeles City Residents Only FOR OFFICE USE ONLY Please PRINT all information legibly Mail completed application to MONTH CHECK ONE I AM FILING AS UTILITY TAX EXEMPTION UNIT New Application Senior Citizen Name Change Disabled Citizen P. O. BOX 53233 LOS ANGELES CA 90053-0233 Address Change YEAR Account Number Re-Certification Middle Initial First Name DAY DATE Received ENTER SOCIAL SECURITY NUMBER BELOW Last Name For record keeping purposes only Service Address City Apartment ApartmentNo./Space No./Space State Zip Code SINGLE RESIDENCE MOBILE HOME Area Code Mailing Address if different from above MM Phone Number Day Time Phone DD YYYY Date of Birth PLEASE ENCLOSE A PHOTOCOPY OF YOUR MOST RECENT UTILITY BILL FOR EACH UTILITY FOR WHICH YOU ARE REQUESTING AN EXEMPTION. THE EXEMPTION CANNOT BE GRANTED IF THE NAME THAT APPEARS ON THE UTILITY BILL IS NOT THE SAME AS THE APPLICANT S NAME Dept. of Water Power Is service included in your rent Yes No Number of People in Household Southern California Gas Lifeline services requested Electric Water Landline Telephone Service Provider Service Company Name Area Code Phone Number Residence Telephone Cellular Telephone Service Provider Additional Telephone Within Same Household Signature REQUIRED on Page 2 Please read carefully 1. I am a user of the utilities at my residential service address within the City of Los Angeles and am responsible for the payment of such utility bills which are all under my name 2. I am either a activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or to be of long-continued and indefinite duration* 3. The combined adjusted gross income as used for purposes of the California Personal Income Tax Law of all members of the household in which I reside is less than 36 050 for the prior calendar year 4. The amount of tax imposed on the above utilities is not paid by a public agency or from funds received from a public agency specifically for the payment of such tax. PLEASE FOLLOW ALL INSTRUCTIONS BELOW AS INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED To shorten the processing time of your application please submit all of the following required documentation that applies to you as a Senior or Disabled Citizen along with this completed form and return to us immediately at the address indicated on the face of this form* IF YOU ARE A SENIOR CITIZEN please submit 1. Proof of Age - attach a copy of your California State Driver s License Calif* State Identification Card or other acceptable proof of age 2. A copy of the entire City of Los Angeles Department of Water and Power DWP bill showing the applicant s name with the current service address please do not send the payment portion only. payment portion only. If not applicable please write NONE* page showing the long distance carrier please do not send the payment portion only.

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