HomeMy WebLinkAbout1816-W Notice Low Income Guidelines Annual UpdateCALIFORNIA PUBLIC UTILITIES COMMISSION
DIVISION OF WATER AND AUDITS
Advice Letter Cover Sheet
Utility Name: GOLDEN STATE WATER COMPANY Date Mailed to Service List: 4/9/2020
District: COMPANY -WIDE
CPUC Utility #: 133 W
Advice Letter #: 1816-W
Tier Z1 EP ❑3 0 Compliance
Authorization D.12-08-044
Description: Update Low Income Program eligibility Income
levels for fiscal year 2020/2021
Protest Deadline (20th Day): 4/29/2o2o
Review Deadline (30th Day): 5/9/2020
Requested Effective Date: 6/1/2020
Rate Impact: $0
0%
The protest or response deadline for this advice letter is 20 days from the date that this advice letter was mailed to the service
list. Please see the "Response or Protest" section in the advice letter for more information.
Utility Contact: Gladys Estrada
Phone: (909) 394-3600 x 527
Email: grosendo@�zswater.com
DWA Contact: Tariff Unit
Phone: (415) 703-1133
Email: Water.Division@cpuc.ca.szov
DATE
STAFF
[ ] APPROVED
Signature:
DWA USE ONLY
[ ] WITHDRAWN
Comments:
Utility Contact: Jon Pierotti
Phone: (909) 394-3600 x 656
Email: Ton.Pierotti@�:swater.com
COMMENTS
[ ] REJECTED
Date:
eo Golden State
W 3 t e t C 0tvl Pa tl�Y
April 9, 2020
Advice Letter No.1816-W (U 133 W)
TO THE PUBLIC UTILITIES COMMISSION OF THE STATE OF CALIFORNIA
Golden State Water Company (GSWC) hereby transmits the following tariff sheets
applicable to its water operations:
Canceling
CPUC Sheet No Title of Sheet CPUC Sheet No.
Revised No. 8680-W Schedule No. LI Revised No. 8287-W
California Alternate Rate for Water
Page 2
Revised No. 8681-W Form No. 20 Revised No. 8288-W
California Alternate Rate for Water
Notice/Application (English & Spanish)
Revised No. 8682-W
Revised No. 8683-W
Revised No. 8684-W
Table of Contents
Page 4
Table of Contents
Page 2
Table of Contents
Page 1
Revised No. 8678-W
Revised No. 8662-W
Revised No. 8679-W
Request
GSWC submits this advice letter to update the eligibility income levels in its lifeline rate
plan, also known as California Alternate Rates for Water ("CARW") program. The CARW
eligibility income levels are patterned after those established in the California Alternate
Rates for Energy ("CARE") Program for energy utilities. This filing, when approved, will
increase the eligibility income levels for GSWC's CARW program for the period June 1, 2020
through May 31, 2021.
Compliance
On March 1, 2020, the California Public Utilities Commission established the eligibility
income levels for fiscal year June 1, 2020 to May 31, 2021, effective June 1, 2020. This advice
letter is being filed to update the revised eligibility income levels on GSWC's CARW tariffs.
GSWC has revised its Form No. 20, California Alternate Rate for Water Application/Notice
and Schedule No. LI, California Alternate Rate for Water.
Advice Letter 1816-W 2 April 9, 2020
The Program eligibility income levels for 2020-2021 will be as follows:
Effective June 1, 2020 through May 31, 2021
Household Size Income Level
1-2
$34,480
3
$43,440
4
$52,400
5
$61,360
6
$70,320
7
$79,280
8
$88,240
Each Additional
$ 8,960
This advice letter is submitted with a Tier 1 designation. GSWC is requesting that this
advice letter and the tariffs become effective June 1, 2020.
Response or Protest
Anyone may submit a response or protest for this AL. When submitting a response or
protest, please include the utility name and advice letter number in the subject line.
A response supports the filing and may contain information that proves useful to the
Commission in evaluating the Advice Letter (AL). A protest objects to the AL in whole or
in part and must set forth the specific grounds on which it is based. These grounds are:
1. The utility did not properly serve or give notice of the AL;
2. The relief requested in the AL 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 AL contain material error or omissions;
4. The relief requested in the AL is pending before the Commission in a formal
proceeding; or
5. The relief requested in the AL requires consideration in a formal hearing, or is
otherwise inappropriate for the AL process; or
6. The relief requested in the AL is unjust, unreasonable, or discriminatory, provided
that such a protest may not be made where it would require re -litigating a prior
order of the Commission.
A protest may not rely on policy objections to an AL where the relief requested in the AL
follows rules or directions established by statute or Commission order applicable to the
utility. A protest shall provide citations or proofs where available to allow staff to properly
consider the protest.
DWA must receive a response or protest via email (or postal mail) within 20 days of the
date the AL is filed. When submitting a response or protest, please include the utility
name and advice letter number in the subject line.
Advice Letter 1816-W 3 April 9, 2020
The addresses for submitting a response or protest are:
Email Address: Mailing Address:
Water.Division@cpuc.ca.gov CA Public Utilities Commission
Division of Water and Audits
505 Van Ness Avenue
San Francisco, CA 94102
On the same day the response or protest is submitted to DWA, the respondent or
protestant shall send a copy of the protest to Golden State Water Company at:
Email Address:
regulatorvaffairs@gswater.com
Mailing Address:
Golden State Water Company
Attn: Gladys Estrada
630 East Foothill Blvd.
San Dimas, CA 91773
Cities and counties that need Board of Supervisors or Board of Commissioners approval to
protest should inform DWA, 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.
Replies
The utility shall reply to each protest and may reply to any response. Any reply must be
received by DWA within five business days after the end of the protest period, and shall
be served on the same day on each person who filed the protest or response to the AL.
The actions requested in this advice letter are not now the subject of any formal filings with
the California Public Utilities Commission, including a formal complaint, nor action in any
court of law.
No individuals or utilities have requested notification of filing of tariffs. Distribution of
this advice letter is being made to the attached service list in accordance with General
Order No. 96-B.
Sincerely,
/s/ Gladys Estrada
Gladys Estrada
Regulatory Analyst
Jim Boothe, CPUC - Division of Water and Audits
Patricia Ma, CPUC- Water Branch,
ORA
Victor Chan, CPUC- Water Branch, ORA
Richard Smith, CPUC- Water Branch, ORA
GOLDEN STATE WATER COMPANY (U 133 W) Revised Cal. P.U.C. Sheet No. 8680-W
630 E. FOOTHILL BLVD. - P.O. BOX 9016 Cancelling Revised Cal. P.U.C. Sheet No. 8287-W
SAN DIMAS, CALIFORNIA 91773-9016
Page 2
Schedule No. LI
California Alternate For Water (CARW)
Domestic Service - Sinyle Familv Accommodation
SPECIAL CONDITIONS
1. Low -Income Household: A Low -Income Household is a household where the total gross annual
income from all sources is no more than shown on the table below based on the number of
persons in the household. Total gross income shall include income from all sources, both taxable
and nontaxable.
(Effective as of June 1, 2020 through May 31, 2021)
Number of Persons in Household
1-2
3
4
5
6
7
8
Each Additional person
Total Gross Annual Income
$ 34,480
$ 43,440
$ 52,400
$ 61,360
$ 70,320
$ 79,280
$ 88,240
$ 8,960
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.
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. A
customer may present documentation showing approval into their energy provider's California
Alternate Rate for Energy Program ("CARE") or provide verification of their household income.
Renewal of a customer's eligibility declaration will be required every two years and may be
required on an annual basis.
3. Commencement of Rate: Eligible customers shall be billed on this schedule commencing with the
next regularly scheduled billing period that follows verification and approval of application by
the Utility.
4. Verification: Information provided by the applicant is subject to verification by the Utility.
Refusal or failure of a customer to provide documentation of eligibility acceptable to the Utility,
upon request by the Utility, shall result in removal from this rate schedule.
5. Notice From Customer: It is the customer's responsibility to notify the Utility if there is a change
of eligibility status. Notification should be made within 30 days of the customer's change in
eligibility.
6. Rebilling: Customers may be re -billed for periods of ineligibility under the applicable rate
schedule.
(T)
(T)
7. Mobile home Park and Master -metered: A reduction will be calculated in the bill of mobile home
park and master -metered customers, who have sub -metered tenants that meet the income
eligibility criteria. A discount will be passed through to eligible customer's).
(To be inserted by utility) Issued By (To be inserted by P.U.C.)
Advice Letter No. 1816-W R. J. Sprowls Date Filed
Decision No. President Effective
Resolution No.
GOLDEN STATE WATER COMPANY (U 133 W) Revised Cal. P.U.C. Sheet No. 8681-W
630 E. FOOTHILL BLVD. - P.O. BOX 9016 Cancelling Revised Cal. P.U.C. Sheet No. 8288-W
SAN DIMAS, CALIFORNIA 91773-9016
Form No. 20
GOLDEN STATE WATER COMPANY NOTICE AND APPLICATION FOR
CALIFORNIA ALTERNATE RATES FOR WATER (CARW) PROGRAM
(To be inserted by utility)
Advice Letter No. 1816-W
Decision No.
Please Refer to Sample Pages of Tariff Book
Issued By
R. J. Sprowls
President
Date Filed
Effective
Resolution No.
(To be inserted by P.U.C.)
GOLDEN STATE WATER COMPANY (U 133 W) Revised Cal. P.U.C. Sheet No. 8682-W
630 E. FOOTHILL BLVD. - P.O. BOX 9016 Cancelling Revised Cal. P.U.C. Sheet No. 8678-W
SAN DIMAS, CALIFORNIA 91773-9016
Page 4
Table of Contents
Rules:
No. 1
Definitions
8664-W, 8665-W
No. 2
Description of Service
1570-W
No. 3
Application for Service
4975-W, 4976-W
No.4
Contracts
777-W
No. 5
Special Information Required on Forms
8673-W, 8674-W, 8675-W
No. 6
Establishment and Re-establishment of Credit
780-W
No. 7
Deposits
4802-W, 4803-W
No. 8
Notices
8676-W, 8677-W, 8612-W
No. 9
Rendering and Payment of Bills
6381-W, 6382-W, 7478-W
No. 10
Disputed Bills
8666-W, 8667-W
No. 11
Discontinuance and Restoration of Service
8597-W, 8598-W, 8668-W, 8669-W,
8670-W, 8671-W, 8603-W, 8604-W,
8605-W, 8672-W
No. 12
Information Available to Public
7011-W, 7012-W
No. 13
Temporary Service
793-W, 794-W
No. 14
Continuity of Service
795-W
No. 14.1
Mandatory Water Conservation Restrictions and
6870-W thru 6878-W
Rationing Plan
No. 15
Main Extensions
7483-W thru 7490, 7742-W, 7492-W,
7493-W, 7494-W, 7495-W, 8228-W,
No. 16
Service Connections, Meters and Customer's Facilities
8231-W thru 8235-W, 8401-W, 8237-W
8238-W, 8239-W, 8240-W, 8241-W
No. 17
Standards for Measurements of Service
2564-W
No. 18
Meter Tests and Adjustment of Bills for Meter Error
6647-W, 6648-W, 6649-W
No. 19
Service to Separate Premises and Multiple Units, and
2959-W, 8001-W
Resale of Water
No. 20
Water Conservation
7068-W
No. 21
Military Family Relief Program
4939-W, 4940-W, 4941-W
No. 22
Customer Information Sharing
5840-W
Sample Forms:
No. 3
Bill For Service
6833-W, 6834-W
No. 4
Reminder Notice
6394-W
No. 6
Notice of Termination
6120-W
No. 7
Notice of Termination, Backflow Prevention Assembly
7051-W
Violation
No. 8
Fire Flow Test Application
7660-W
No. 14
Uniform Fire Hydrant Service Agreement
2449-W, 2450-W, 2451-W, 2452-W
No. 15
Main Extension Contract - Individuals
5738-W
No. 16
Main Extension Contract
5739-W, 5740-W, 5741-W
No. 17
Income Tax Component of Contribution Agreement
8242-W, 8243-W
No. 18
Waste of Water Notice
6985-W
No. 19
Customer Service Door Notice
6986-W
No. 20
California Alternate Rate for Water Application/Notice
8681-W (T)
No. 24
Confidentiality and Non -Disclosure Agreement
5841-W, 5842-W, 5843-W
(To be inserted by utility)
Advice Letter No. 1816-W
Decision No.
Issued By
R. J. Sprowls
President
Date Filed
Effective
Resolution No.
(To be inserted by P.U.C.)
GOLDEN STATE WATER COMPANY (U 133 W) Revised Cal. P.U.C. Sheet No. 8683-W
630 E. FOOTHILL BLVD. - P.O. BOX 9016 Cancelling Revised Cal. P.U.C. Sheet No. 8662-W
SAN DIMAS, CALIFORNIA 91773-9016
Page 2
Table of Contents
Subiect Matter of Sheet
Schedule Number
CPUC Sheet No.
Rate Scheduels:
All Districts
Utility Fee Surcharge
OF
8248-W
Private Fire Service
AA-4
4801-W, 3285-W
Public Fire Service
AA-5
2931-W
Cross Connection Control Fee
CCCF
7506-W
Fire Flow Testing Charge
FF
7659-W
California Alternate Rates for Water
LI
8310-W, 8680-W
Arden -Cordova District
General Metered Service
AC-1
8523-W, 8641-W, 8642-W, 8643-W
Flat Rate Service
AC-2
8524-W, 8644-W, 8645-W
Bay Point District
Residential Metered Service
BY-1-R
8528-W, 8500-W,8426-W
Non -Residential Metered
BY-1-NR
8527-W, 8499-W, 8425-W
Service
Clearlake District
General Metered Service
CL-1
8531-W, 8501-W, 8460-W*
Los Osos District
Residential Metered Service
LO-1-R
8566-W, 8648-W, 8649-W
Non -Residential Metered
LO-1-NR
8565-W, 8646-W, 8647-W
Service
Recycled Water Service
LO-RCW
8567-W, 8650-W, 8651-W
Water Conservation
14.1-LO
7300-W, 7301-W, 7302-W, 7303-W,
7304-W, 7305-W
Metropolitan District
Residential Metered Service
ME-1-R
8549-W, 8617-W, 8618-W
Non -Residential Metered
ME-1-NR
8548-W, 8615-W,8616-W
Service
Reclaimed Water Service
ME-3
8550-W, 8619-W, 8620-W
(C)
(Continued)
(To be inserted by utility) Issued By (To be inserted by P.U.C.)
Advice Letter No. 1816-W R. J. Sprowls Date Filed
Decision No. President Effective
Resolution No.
GOLDEN STATE WATER COMPANY (U 133 W) Revised Cal. P.U.C. Sheet No. 8684-W
630 E. FOOTHILL BLVD. - P.O. BOX 9016 Cancelling Revised Cal. P.U.C. Sheet No. 8679-W
SAN DIMAS, CALIFORNIA 91773-9016
Page 1
Table of Contents
s
The following tariff sheets contain all effective rates and rules affecting rates and service of the utility, together with information relating thereto:
Subiect Matter of Sheet
Title Page
Table of Contents
Sheet No.
4905-W
8684-W, 8683-W, 8661-W, 8682-W (T)
Preliminary Statements: 8370-W, 7005-W, 3140-W, 3141-W, 3142-W, 6940-W, 5096-W*, 5097-W*, 5102-W, 5223-W, 5322-W, 6477-W, 6478-W,
6479-W, 7075-W, 7076-W, 5607-W, 5848-W, 5937-W, 6101-W, 6103-W, 6123-W, 6225-W, 6475-W, 6559-W, 6652-W, 6858-W, 7129-W, 6938-W,
7368-W, 7441-W, 7442-W, 7451-W, 7481-W, 7728-W, 7730-W, 7747-W, 7748-W, 7749-W, 7750-W, 7756-W, 7994-W, 8007-W, 8246-W, 8365-W,
8366-W, 8367-W, 8418-W, 8419-W, 8494-W, 8495-W
Tariff Area Maps:
Arden - Cordova
Arden
6837-W
Cordova
6838-W
Barstow
5560-W
Bay,
8189-W
Calipatria-Niland
6846-W
Clearlake
6839-W
Claremont
8487-W
Desert
Morongo Valley
8223-W, 6427-W
Apple Valley North
5802-W
Apple Valley South
8221-W
Desert View
8222-W
Lucerne Vallev
5805-W
Los Osos
Edna Road
8198-W
Los Osos
5253-W
Metropolitan
Artesia
8292-W
Norwalk
7732-W
Bell -Bell Gardens
6675-W
Florence -Graham
8294-W
Hollydale
8295-W
Culver Citv
8293-W
Southwest
8196-W
Willowbrook
6842-W
Orange County
Bolsa Chica
4381-W
Cowan Heights
8251-W
Cvpress-Los Alamitos -Stanton
8252-W
Placentia-Yorba Linda
6844-W
San Dimas 8226-W
San Gabriel Valley
South Arcadia
8285-W
South San Gabriel
8005-W
Santa Maria
Cypress Ridge
8254-W
Lake Marie
5705-W
Orcutt
5558-W
Sisquoc
5257-W
Tanglewood
8638-W
Nipomo
8637-W
Simi Valley
8639-W
Wrightwood
6428-W
(Continued)
(To be inserted by utility) Issued By (To be inserted by P.U.C.)
Advice Letter No. 1816-W R. J. Sprowls Date Filed
Decision No. President Effective
Resolution No.
Form No. 20
GOLDEN STATE WATER COMPANY NOTICE AND APPLICATION FOR
CALIFORNIA ALTERNATE RATES FOR WATER (CARW) PROGRAM
Program Description
The California Public Utilities Commission has authorized Golden State Water Company (GSWC) to implement a Low
Income Rate Assistance Program to assist low-income families. GSWC's California Alternate Rates for Water (CARW)
program provides a monthly credit for eligible customers based upon the same income qualification guidelines that are
used by the electric and gas California Alternate Rate for Energy (CARE) programs.
If you already participate in the CARE program of participating energy utilities you may also qualify for GSWC's CARW
program by submitting a copy of a current utility bill showing your eligibility for CARE and a signed and completed GSWC CARW
application. Customers, who do not participate in these programs, can enroll by filling out and submitting this CARW application
to GSWC. For questions please call GSWC's CARW Hotline at (866) 360-2279. All enrollments are subject to the program
guidelines and qualifications. For more information please visit our website at www.aswater.com. The CARW program also
extends eligibility to customers in mobile homes who receive their water through sub -metered service, non-profit group living
facilities, agricultural employee housing facilities and migrant worker housing centers that are enrolled in the CARE programs.
The CARW discount becomes effective after your application and proof of income have been verified and approved, if proof of
income is required by GSWC.
Program Qualifications
• The GSWC bill must be in your name and the address must be your primary residence or you must be a tenant
receiving water service by a sub -metered system in a mobile home park.
• You may not be claimed as a dependent on another person's tax return.
• You must reapply each time you move, the CARW discount does not automatically transfer to another residence.
• You must renew your application every two years, or sooner, if requested.
• You must notify GSWC within 30 days if you become ineligible for CARW.
• Your total gross annual income of all persons living in your household cannot exceed the income levels below:
Income Guidelines
(Effective as of June 1, 2020 to May 31, 2021)
Household Size
1-2
4
5
6
7
8
Each Additional person
Total Combined Income from
All Sources
$ 34,480
$ 43,440
$ 52,400
$ 61,360
$ 70,320
$ 79,280
$ 88,240
$ 8,960
Household Income Eligibility
CHECK all programs you or someone in your household participate in. You will be enrolled in the CARW Program depending
on your household size and income.
O Pensions
O Social Security
O SSI, SSP
O Interest /dividends from: Savings Accounts, stocks, bonds or Retirement Accounts
O Wages and/or Profits from Self -Employment
O Rental or royalty income
O Unemployment benefits
O Disability or Worker's Compensation Payments
O Scholarships, Grants or Other Aid for Living Expenses
O Insurance or Legal settlements
O Spousal or child Support
O Cash and/or Other Income
Public Assistance Program Eligibility:
CHECK all programs you or someone in your household participate in
O Medi-Cal/Medicaid (under age 65)
O Medi-Cal/Medicaid (age 65 and older)
O SSI
O Food Stamp/SNAP
O LIHEAP
O Head Start Income Eligible (Tribal Only)
O WIC
O Healthy Families A & B
O TANF/Tribal TANF
O National School Lunch (NSL)
O Bureau of Indian Affairs General Assistance
GOLDEN STATE WATER COMPANY
APPLICATION FOR
CALIFORNIA ALTERNATE RATES FOR WATER (CARW) PROGRAM
(Para recibir una aplicacion en espanol, favor de llamar)
CARW HOTLINE (866) 360-2279
APPLICATION INFORMATION (please print clearly)
Applicant Name
❑ 1 am a sub -metered tenant of a mobile home park or apartment complex
Golden State Water Company Account Number 1-I-I-I-I_I-I-I-I-II-II-I
Service Address
Mailing Address
if different from service address
Telephone No. (home)
(work)
Number of people living in your household: Adults 1_11-1 + Children 1_11-1 = Total 1_II_I
Total Gross Annual Income of Household
Declaration (Please read and sign)
By signing below, I certify under penalty of perjury that this information is true and correct under the laws of the
State of California. I will provide proof of income, if asked, and I will notify GSWC of any changes that affect my
eligibility. I understand that if I receive the discount without meeting the qualifications for it, I may be required to pay
back the discount I received. I understand that GSWC can share my information with other utilities or their agents to
enroll me in their assistance programs. I understand that an incomplete application form will be returned to me for
missing information and that this will delay the processing of my application.
Customer Signature
Date
Email completed application to:
customerservice(a).aswater.com
or
Mail completed application to:
Golden State Water Company
CARW Program
P.O. Box 9016
San Dimas, California 91773
FOR GOLDEN STATE WATER COMPANY USE ONLY
Date received Date Verified Verified By
Form No. 20
GOLDEN STATE WATER COMPANY AVISO Y APLICACION PARA EL PROGRAMA
DE CALIFORNIA PARA TARIFAS ALTERNAS (CARW)
Descripcion de Programa
La Comision de Servicios Publicos de California ha autorizado a Golden State Water Company a implementar un programa para
asistencia de tarifas reducidas para asistir a familias de bajos recursos. El programa de GSWC de California de Tarifas Alternas
De Agua — CARW (por sus siglas en ingl6s) ofrece un credito mensualmente para sus clientes elegibles para el programa que es
Basado en los mismos requisitos de ingresos usados por los programas CARE de las companias de gas y electricidad.
Si usted ya participa en el programa CARE de servicios publicos de energia usted tambi6n podria calificar para el programa
de CARW de GSWC al enviar una copia reciente de su factura de servicio publico la cual indica su elegibilidad para el programa
CARE y una solicitud completa y firmada del programa CARW de GSWC. Clientes que no participan en estos programas, pueden
calificar al enviar una solicitud a GSWC. Para preguntas, por favor Ilame la linea gratuita de CARW (866) 360-2279. Todas las
inscripciones estan sujetas a las directrices del programa y las cualificaciones. Para obtener mas informacidn, visite nuestro sitio web
en www.ciswater.com. El programa CARW tambien extiende elegibilidad para los clientes en cases moviles que reciben el agua traves
del servicio sub-medidor, viviendas grupales no-lucrativas, las viviendas de los empleados agricultural y centros de vivienda para
trabajadores migrantes que estan inscritos en los programas de CARE. El descuento CARW sera efectivo despues de que su
aplicacidn y prueba de ingresos sea verificada y aprobada, si es que la prueba de ingresos es necesaria por GSWC.
Requisitos del Programa
• La factura de agua debe estar bajo su nombre o recibir servicio de agua con un sistema de sub-medidor en un parque de
casas moviles o en un complejo de apartamentos.
• Nadie mas puede incluirlo como dependiente en sus impuestos.
• Debe de aplicar cada vez que se mude de casa, el descuento no se transfiere automaticamente a otra residencia
• Debe de renovar su aplicacion cada dos (2) anos o antes si es requerido.
• Debe notificar a la compania de agua dentro de 30 dias si su elegibilidad para CARW termina.
• El total del ingreso bruto anual de su hogar no podra exceder los de la tabla siguiente:
Limites de ingresos del Programa
(Efectivo junio 1, 2020 hasta el 31 de mayo de 2021)
Numero de personas
Ingresos total anual
que viven en su casa
combinado
1-2
$ 34,480
3
$ 43,440
4
$ 52,400
5
$ 61,360
6
$ 70,320
7
$ 79,280
8
$ 88,240
Para cada persona adicional,
$ 8,960
agregar
Elegibilidad por ingresos familiares
MARQUE todas las fuentes de ingresos familiares. Sera inscripto en el Programa de (CARW, por sus siglas en ingl6s) segun el tamano
de su familia y sus ingresos.
o Pensiones
o Seguro Social
o SSI, SSP
o Inter6s o dividendos de: Cuentas de ahorros, acciones, bonos o Beneficios de Jubilacion
o Ingresos de alquiler o regalias
o Beneficios por incapacidad
o Compensacion al trabajador
o Becas, pr6stamos de escuela y otra ayuda financiera
o Ganancias de autoempleo
o Indemnizaciones de seguro o legales
o Apoyo cdnyuge o para los ninos
o Dinero en efectivo o Otra ayuda
Eligibilidad Para El Programa De Asistencia Publica:
MARQUE todos los programas en los que parti usted o alguien en su casa participant:
o Medi-Cal/Medicaid (menor de 65 anos) o Programa Especial de Nutrici6n Suplementaria para
Mujeres, Bebes y Ninos (WIC, por sus siglas en ingl6s)
o Medi-Cal/Medicaid (65 ahos o mas) o Healthy Families A & B
o Ingreso de Seguro Suplementario (SSI, por sus o Asistencia Temporal para Familias Necesitadas (TANF,
siglas en ingl6s) por sus siglas en ingl6s) o TANF tribal
o Cupones para alimentos/Programa Suplementario o Almuerzos GRATIS del Programa Nacional de
de Asistencia Nutricional (SNAP, por sus siglas en Almuerzos Escolares
ingl6s)
Programa de Asistencia Energetica para Hogares o Oficina de Asistencia General para Asuntos de los
de Bajos Ingresos (LIHEAP, por sus siglas en Indigenas
ingl6s)
ReOne los requisitos para Head Start (solo Tribal)
GOLDEN STATE WATER COMPANY
APLICACION PARA EL PROGRAMA
DE TARIFAS DE AGUA ALTERNAS (CARW)
CARW HOTLINE (866) 360-2279
INFORMACION DEL CLIENTE (Favor de Imprimir con Claridad)
Su Nombre
❑ Soy cliente inquilino con un sub-medidor en un parque para casas moviles o complejo de apartamentos
Numero de cuenta principal I-I-1-I-1-I-I-1-I-11-II-I
Domicilio
Direccion de correo
Si difiere de su domicilio
No. de Telefono (Casa) (Trabajo)
Numero de personas viviendo en su hogar: Adultos 1_11_1 + Ninos I -II -I = Total I-11-I
Ingreso bruto anual de los que viven en su hogar
Declaracion (Por favor lea y firme)
Al firmar abajo certifico bajo pena de perjurio que la informacion es verdadera y correcta bajo las leyes de
California. Acepto proporcionar pruebas de mis ingresos, si me to piden y notificare a mi companfa de
agua de cualquier cambio que afecte mi elegibilidad. Entiendo que si recibo el descuento sin reunir los
requisitos se me podrfa pedir que pague el descuento recibido. Yo entiendo que GSWC puede compartir
mi informacion con otros servicios publicos o sus agentes para inscribirme en sus programas de asistencia.
Tengo entendido que una solicitud incompleta sera devuelta a mi falta de informacion y de que esto retrasara
el procesamiento de la solicitud.
Firma del Cliente
Fecha
Llenar la solicitud y enviarla por correo electronico a:
customerservice(a)gswater.com
Llenar la solicitud y enviarla por correo a:
Golden State Water Company
CARW Program
P.O. Box 9016
San Dimas, California 91773
1-866-360-2279
PARA USO DE GOLDEN STATE WATER COMPANY SOLAMENTE
Date received Date Verified Verified By
All Districts 116 Labels Page 1 of 9 Revised 01/29/2020
DIRECTOR OF PUBLIC SERVICES
TOWN OF APPLE VALLEY
14955 DALE EVANS PARKWAY
APPLE VALLEY, CA 92307
CITRUS HEIGHTS WATER DISTRICT
6230 SYLVAN ROAD
CITRUS HEIGHTS CA 95610
FAIR OAKS WATER DISTRICT
10317 FAIROAKS BLVD.
FAI ROAKS, CA 95628
BAY POINT MUNICIPAL ADVISORY COUNCIL
3105 WILLOW PASS ROAD
BAY POINT, CA 94565-3149
CITY OF MORRO BAY
ROB LICVICK, PE/PLS
955 SHASTA AVENUE
MORRO BAY, CA 93442
CONTRA COSTA COUNTY
CONSERVATION & DEVELOPMENT
30 MUIR ROAD
MARTINEZ, CA 94553
HIGHLANDS WATER COMPANY
14580 LAKESHORE DRIVE
CLEARLAKE, CA 95422-8100
COMMUNITY SERVICES DIRECTOR
CITY OF CLAREMONT
1616 MONTE VISTA AVENUE
CLAREMONT, CA 91711
CARMICHAEL WATER DISTRICT
7837 FAIR OAKS BLVD.
CARMICHAEL, CA 95608-2405
CITY OF FOLSOM
50 NATOMA STREET
FOLSOM, CA 95630
CITY OF BRENTWOOD
PUBLIC WORKS OPERATIONS
ERIC BRENNEN, WATER OPERATIONS MANAGER
2201 ELKINS WAY
BRENTWOOD, CA 94513
CONTRA COSTA WATER DISTRICT
P. O. BOX H2O
CONCORD, CA 94520
CITY OF MARTINEZ
525 HENRIETTA AVENUE
MARTINEZ, CA 94553
CAMBRIA COMMUNITY SERVICES DIST.
1316 TAMSON DRIVE - SUITE 201
P.O. BOX 65
CAMBRIA, CA 93428
All Districts 116 Labels Page 2 of 9 Revised 01/29/2020
LOS OSOS CSD
2122 9T" STREET
LOS OSOS, CA 93402
CITY OF SANTA MARIA
2065 EAST MAIN STREET
SANTA MARIA, CA 93454
CITY CLERK & CITY ATTORNEY
CITY OF GUADALUPE
918 OBISPO STREET
GUADALUPE, CA 93434
ROBERT MILLER, WALLACE GROUP
NIPOMO MESA MANAGEMENT AREA
612 CLARION COURT
SAN LUIS OBISPO, CA 93401
COUNTY CLERK
COUNTY OF SACRAMENTO
P. O. BOX 839
SACRAMENTO, CA 95812-08397
COUNTY COUNSEL
COUNTY OF SAN LUIS OBISPO
COUNTY GOVERNMENT CENTER - #D-320
SAN LUIS OBISPO, CA 93408
CITT' • _ • �� •
DIRECTOR OF PUBLIC WORKS
P. • BOX 130
DOWNEY, CA 90241
COMMUNITY SERVICVE DISTRICT
P O BOX 6064
LOS OSOS, CA 93412
CITY ATTORNEY
CITY OF CLEARLAKE
14050 OLYMPIC DRIVE
CLEARLAKE, CA 95422
COUNTY GOVERNMENT CENTER
1050 MONTEREY STREET - ROOM 207
SAN LUIS OBISPO, CA 93408
CITY CLERK & CITY ATTORNEY
CITY OF SIMI VALLEY
2929 TAPO CANYON ROAD
SIMI VALLEY, CA 93065
COUNTY CLERK
COUNTY OF SAN LUIS OBISPO
1055 MONTEREY STREET - SUITE #13-120
SAN LUIS OBISPO, CA 93408
COUNTY COUNSEL
105 EAST ANAPAMU STREET, RM. 201
SANTA BARBARA, CA 93101
CITY OF HAWTHORNE
4455 W. 126TH STREET
HAWTHORNE, CA 90250
All Districts 116 Labels Page 3 of 9 Revised 01/29/2020
CITY OF HUNTINGTON PARK
WATER DEPARTMENT
6550 MILES STREET
HUNTINGTON PARK, CA 90255
CITY OF LAKEWOOD
WATER DEPARTMENT
P.O. BOX 220
LAKEWOOD, CA 90714-0220
HONORABLE MAYOR ERIC GARCETTI
CITY OF LOS ANGELES
200 N. SPRING STREET - ROOM 303
LOS ANGELES, CA 90012
CITY OF NORWALK
WATER DEPARTMENT
12700 NORWALK BLVD
NORWALK, CA 90650
CITY OF TORRANCE
WATER DEPARTMENT
3031 TORRANCE BLVD.
TORRANCE, CA 90503
CITY OF INGLEWOOD
ONE MANCHESTER BLVD. - SUITE 900
P. O. BOX 6500
INGLEWOOD, CA 90301
LONG BEACH WATER DEPARTMENT
GENERAL MANAGER, CHRIS GARNER
1800 E. WARDLOW ROAD
LONG BEACH, CA 90807
CITY OF LOS ANGELES
DEPARTMENT OF WATER & POWER
P. O. BOX 51111
LOS ANGELES, CA 90051-0100
CITY OF SANTA FE SPRINGS
WATER DEPARTMENT
- ROOM #5 11736 E. TELEGRAPH ROAD
SANTA FE SPRINGS, CA 90670
MAYWOOD MUTUAL WATER - NO. 2
3521 EAST SLAUSON STREET
MAYWOOD, CA 90270
PICO COUNTY WATER DISTRICT
P O BOX 758
PICO RIVERA, CA 90660-0768
CALIFORNIA WATER SERVICE
RANCHO DOMINGUEZ DISTRICT
2632 WEST 237T" STREET
TORRANCE, CA 90505-5272
MAYWOOD MUTUAL WATER - NO. 3
6151 HELITROPE AVENUE
MAYWOOD, CA 90270-3418
ROBERT KELLY, VP REGULATORY AFFAIRS
SUBURBAN WATER SYSTEMS
1325 N. GRAND AVENUE, SUITE 100
COVINA, CA 91724-4044
All Districts 116 Labels Page 4 of 9 Revised 01/29/2020
CENTRAL BASIN MWDR
GENERAL MANAGER
6252 TELEGRAPH ROAD
COMMERCE, CA 90040-2512
HILDA SOLIS - 1ST DISTRICT
L.A. COUNTY BOARD OF SUPERVISORS
856 KENNETH HAHN HALL OF ADMIN
500 WEST TEMPLE STREET
LOS ANGELES, CA 90012
CITY CLERK
CITY OF BELL
6330 PINE AVENUE
BELL, CA 90201
CITY ATTORNEY & CITY CLERK
CITY OF CERRITOS
P.O. BOX 3130
CERRITOS, CA 90703
CITY ATTORNEY & CITY CLERK
CITY OF HAWAIIAN GARDENS
21815 PIONEER BLVD.
HAWAIIAN GARDENS, CA 90716
CITY ATTORNEY & CITY CLERK
CITY OF NORWALK
12700 NORWALK BLVD.
NORWALK, CA 90650
COUNTY CLERK
COUNTY OF LOS ANGELES
12400 IMPERIAL HIGHWAY
NORWALK, CA 90650
WEST BASIN MWD
JULIE FRAZEIR-MATHEWS — EXECUTIVE ASST.
17140 S. AVALON BLVD. - SUITE 210
CARSON, CA 90746-1296
CITY ATTORNEY & CITY CLERK
CITY OF ARTESIA
18747 CLARKSDALE AVENUE
ARTESIA, CA 90701
CITY ATTORNEY & CITY CLERK
CITY OF CARSON
701 E. CARSON STREET
CARSON, CA 90745
CITY ATTORNEY & CITY CLERK
CITY OF EL SEGUNDO
350 MAIN STREET
EL SEGUNDO, CA 90245
CITY ATTORNEY & CITY CLERK
CITY OF INGLEWOOD
ONE MANCHESTER BLVD.
P. O. BOX 6500
INGLEWOOD, CA 90301
CITY ATTORNEY & CITY CLERK
CITY OF SOUTH GATE
8650 CALIFORNIA AVENUE
SOUTH GATE, CA 90280
COUNTY CLERK
COUNTY OF ORANGE
12 CIVIC CENTER PLAZA
SANTA ANA, CA 92702
All Districts 116 Labels Page 5 of 9 Revised 01/29/2020
COUNTY COUNSEL
CITY OF ORANGE
333 W. SANTA ANA BLVD., 4T" FLOOR
SANTA ANA, CA 92701
CALIFORNIA DEPT. OF FORESTRY
7105 AIRWAY DRIVE
YUCCA VALLEY, CA 92284
COUNTY WATER
P. O. BOX 5001
VICTORVILLE, CA
CALIFORNIA DEPARTMENT OF CORRECTIONS
P. O. BOX 5001
7018 BLAIR ROAD
CALIPATRIA, CA 92233
CALIFORNIA DEPT. OF FORESTRY HDQTRS
3800 N. SIERRA WAY
SAN BERNARDINO, CA 92405
DAGGETT COMMUNITY SERVICE
P.O. BOX 308
92393-5001 DAGGETT, CA 92327
RAYMOND CASTILLO, CHAIRMAN
COUNTY ADMINISTRATION CENTER
940 W. MAIN STREET - #209
EL CENTEO, CA 92243-2871
SEELEY COUNTY WATER DISTRICT
P. O. BOX 161
SEELEY, CA 92273
VICTOR VALLEY WATER DISTRICT
14342 CIVIC DRIVE
P O BOX 5001
VICTORVILLE, CA 92392
CITY OF ANAHEIM
CITY CLERK'S OFFICE
200 S. ANAHEIM BLVD. - SUITE 217
ANAHEIM, CA 92805
JURG HEUBERGER, CEP, EXECUTIVE OFFICER
LAFCO
1122 W. STATE STREET, SUITE D
EL CENTRO, CA 92243
SERRANO WATER DIST. - VILLA PARK
18021 EAST LINCOLN STREET
VILLA PARK, CA 92667
WESTMORLAND WATER COMPANY
P.O. BOX 698
WESTMORLAND, CA 92281
CITY OF ALHAMBRA UTILITIES DEPT.
111 S. FIRST AVENUE
ALHAMBRA, CA 91801
All Districts 116 Labels Page 6 of 9 Revised 01/29/2020
CITY OF CALEXICO WATER CO.
608 HEBER AVENUE
CALEXICO, CA 92231
CITY OF GLENDORA
116 EAST FOOTHILL BLVD.
GLENDORA, CA 91740
CITY OF IMPERIAL
WATER DEPARTMENT
420 S. IMPERIAL AVENUE
IMPERIAL, CA 92251
CITY OF MONTEREY PARK WATER CO.
320 W. NEWMARK AVENUE
MONTEREY PARK, CA 91754
CITY OF WEST COVINA
WATER DEPARTMENT
825 S. SUNSET AVENUE
WEST COVINA, CA 91790
CITY ATTORNEY
CITY OF BARSTOW
222 E. MOUNTAIN VIEW STREET
BARSTOW, CA 92311
CITY ATTORNEY
CITY OF COVINA
125 E. COLLEGE STREET
COVINA, CA 91723
CITY OF COVINA
125 EAST COLLEGE STREET
COVINA, CA 91723-2199
HEBER PUBLIC UTILITY DISTRICT
P. O. BOX H
HEBER, CA 92249
CITY OF LA PALMA
7822 WALKER STREET
LA PALMA, CA 90623
ATTN: JEFF MONEDA, PW DIRECTOR
CITY OF MONROVIA WATER COMPANY
415 S. IVY AVENUE
MONROVIA, CA 91016
CITY OF WESTMINSTER
8200 WESTMINSTER BLVD.
WESTMINSTER, CA 92683
CITY ATTORNEY
CITY OF CLAREMONT
P. O. BOX 880
CLAREMONT, CA 91711
CITY ATTORNEY
CITY OF CYPRESS
5275 ORANGE AVENUE
CYPRESS, CA 90630
All Districts 116 Labels Page 7 of 9 Revised 01/29/2020
CITY ATTORNEY
CITY OF IRWINDALE
5050 N. IRWINDALE AVENUE
IRWINDALE, CA 91706
CITY ATTORNEY
KARL H. BERGER, HENSLEY LAW GROUP
CITY OF MONTEREY PARK
2600 WEST OLIVE AVENUE, SUITE 500
BURBANK, CA 91505
CITY ATTORNEY, BONIFACIO GARCIA
CITY OF ROSEMEAD
8838 E. VALLEY BLVD.
ROSEMEAD, CA 91770
CITY ATTORNEY
CITY OF TEMPLE CITY
9701 LAS TUNAS DRIVE
TEMPLE CITY, CA 91780
CITY CLERK
CITY OF EL MONTE
11333 VALLEY BLVD.
EL MONTE, CA 91731
CITY CLERK
CITY OF MONROVIA
415 S. IVY AVENUE
MONROVIA, CA 91016
COUNTY COUNSEL
COUNTY OF SAN BERNARDINO
385 N. ARROWHEAD AVENUE, 2ND FLOOR
SAN BERNARDINO, CA 92415-0140
CITY ATTORNEY
CITY OF LA VERNE
3660 `D' STREET
LA VERNE, CA 91750
CITY ATTORNEY
CITY OF ORANGE
300 E. CHAPMAN AVENUE
ORANGE, CA 92666
CITY ATTORNEY
CITY OF STANTON
7800 KATELLA AVENUE
STANTON, CA 90680
CITY CLERK
CITY OF COVINA
125 E. COLLEGE STREET
COVINA, CA 91723
CITY CLERK
CITY OF LA PALMA
7822 WALKER STREET
LA PALMA, CA 90680
CITY MANAGER
CITY OF TEMPLE CITY
9701 LAS TUNAS DRIVE
TEMPLE CITY, CA 91780
= _ - %
NILAND CHAMBER OF •
P. • BOX •
All Districts 116 Labels Page 8 of 9 Revised 01/29/2020
COUNTY CLERK
COUNTY OF LOS ANGELES
12400 IMPERIAL HIGHWAY
NORWALK, CA 90650
MICHAEL KENT
CONTRA COSTA HEALTH SERVICES
597 CENTER AVENUE, SUITE 320
MARTI N EZ, CA 94553-4635
CITY OF BARSTOW
222 E. MOUNTAIN VIEW ST. - SUITE A
BARSTOW, CA 92311
NAVAL FACILITIES ENGINEERING COMMAND
REA D. ESTRELLA
SOUTHWEST DIVISION
1220 PACIFIC HIGHWAY
SAN DIEGO, CA 92132
WATER ISSUES COMMITTEE
WRIGHTWOOD PROPERTY OWNERS ASSOC.
P O BOX 487
WRIGHTWOOD, CA 92397
CITY CLERK
CITY OF PLACENTIA
401 E. CHAPMAN AVENUE
PLACENTIA, CA 92870
CITY OF FULLERTON
303 W. COMMONWEALTH AVENUE
FULLERTON, CA 92631
SCOTT BLAISING
BRAUN BLAISING McLAUGHLIN & SMITH PC
915 L STREET, SUITE 1270
SACRAMENTO, CA 95814
CITY OF ANTIOCH
P O BOX 5007
ANTIOCH, CA 94531
CITY OF EL CENTRO WATER
307 W. BRIGHTON AVENUE
EL CENTRO, CA 92243
MONTE VISTA WATER DISTRICT
10575 CENTRAL AVENUE
MONTCLAIR, CA 91763
MORONGO VALLEY COMMUNITY
SERVICE DISTRIBUTION
P O BOX 46
MORONGO VALLEY, CA 92256
WALNUT VALLEY WATER DISTRICT
271 S. BREA CANYON ROAD
WALNUT, CA 91789
CITY OF
DEPARTMENTWATER
CENTER#1 CIVIC DRIVE
All Districts 116 Labels Page 9 of 9 Revised 01/29/2020
CITY OF WHITTIER COUNTY OF VENTURA
13230 PENN STREET 800 S. VICTORIA STREET
WHITTIER, CA 90602 VENTUTRA, CA 93009