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Data-Free Copy - COVID-19 Assistance Program

2. This form should only be completed if you are applying for the COVID-19 Assistance Program because you have lost your employment status directly related to the pandemic. If you are eligible for the standard Low Income program, please utilize the Low Income application.

4. First Name*

5. Last Name*

7. Address1*

9. City*

10. State*

11. Zip*

13. Customer Account Number*

    Customer number can be found on the upper right hand corner of the Utility bill.

14. Electric Utility Account Number*

    Account number can be found on the upper right hand corner of the Utility bill.

16. Telephone Number*

17. Email

19. Has your household income been impacted directly related to COVID-19?*
    -- Select One --YesNo

21. How has your income been impacted by COVID-19?*

    Example: Employer closed business, laid off, temporary unemployment, etc...

22. Date of Job loss*
    Date of Job loss

24. Have you or someone in your household filed for unemployment benefits?*

25. What is the total combined household income after COVID-19 changes?*

26. How many people currently live in the home?*

28. List the First and Last Name, Date of Birth, and Age of each person living in the home.*

    Example: 1. John Doe, DOB 1/15/1980, 40 yrs old

30. Please Read and Select a response to the following statements

32. I understand that this assistance will apply ONLY to the Electric portion of my utility bill.*
    -- Select One --YesNo

34. I understand this assistance will begin on my next month's utility bill.*
    -- Select One --YesNo

36. I understand that this assitance will be applied to my bill each month, for 6 months from date of approval.*
    -- Select One --YesNo

38. IMPORTANT: For verification purposes, please attach all forms showing loss of employment for the household. This can be a letter from your employer, or proof that you applied for unemployment benefits after March 19, 2020.

40. Upload proof of unemployment due to COVID-19.*

41. Upload proof of unemployment due to COVID-19.

43. Upload proof of unemployment due to COVID-19.

44. Upload proof of unemployment due to COVID-19.

46. By typing your name below, you are authorizing the City of Colton to verify your household income for the purpose of qualifying you for the COVID-19 Assistance Program.*

    Please type First and Last Name

48. By typing your name below, you are stating that all information listed above is true and correct under penalty of perjury under laws of California*

    Please type First and Last Name

50. Date of Application Request*
    Date of Application Request

Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit Submit and Print

* indicates a required field