TEP Lifeline

Customer Assistance Application
Date Submitted

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Would like assistance with
What is your household/family size?
My income is at or below $2,660 a month.
My income is at or below $3,607 a month.
My income is at or below $4,553 a month.
My income is at or below $5,500 a month.
My income is at or below $6,446 a month.
My income is at or below $7,393 a month.
My income is at or below $8,340 a month.
My income is at or below $9,287 a month.
My monthly income is at or below $9,287 + $947 per additional person.
Application for Discount
Account Holder Name

First NameLast Name
Account Number
Include any leading zeroes, if applicable
Account Address

Street Address

Street Address Line 2

CityState

Zip Code
Account Holder Email
example@example.com
Account Holder Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please type your name, which will serve as your signature
I authorize TEP to contact any source necessary to establish the accuracy of information given by me that pertains to the verification of my eligibility. I am voluntarily providing my necessary personal information to complete this form. I understand I may be required to provide additional documentation to validate my eligibility. I understand that if I become ineligible for the discount, I must notify TEP immediately. I understand that if I move to a different service address, a new application is required and the discount will not be applied at the new address until the application has been received and approved. I further understand that discounts are limited to my primary account only. I further authorize TEP to provide my contact and account information (which includes usage, billing and past due balance information) to organizations that provide bill payment
assistance to customers.

I hereby declare, under penalty of law, that the income information provided on this form is true and accurate to the best of my knowledge and belief. My signature below certifies acknowledgement that any person obtaining a discount based on false information will be required to repay all discount amounts and all penalties allowable by law.

You may voluntarily provide the personal information required to complete this form. TEP uses this information to fulfill the purpose for which it was obtained. To find out more about the categories of personal information TEP collects and the purposes for which such information will be used, please refer to our Privacy Policy.
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Customer Assistance Application

Application for Discount