Name on Bill Account Number Service Address TexasAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Phone Number Email Address (Used for confirmation) Preferred language I am currently on a fixed income and receive income or benefits from one or more of the following: Supplemental Security Income (SSI), Medicaid, Self Sufficiency Programs (SSP), and Social Security Disability Insurance (SSDI). YesNo
Income level qualification:
Number of people in the household Annual household income (Refer to the income eligibility guidelines table for help.)
1. I understand this is an initial application and Blue Topaz Utilities will follow-up with me after formal enrollment with details regarding my discount. 2. I will notify Blue Topaz Utilities if my average annual household income or the number of people living in my household changes by submitting a new application online or by calling 936-756-7400. 3. I understand I may be required to provide proof of household income and household size if asked. Information will be made available to NW Natural and person or entities working on behalf of NW Natural to implement this program. 4. I understand this discount will not apply to charges incurred before enrollment, but only new charges after enrollment (enrollment may take up to 30 days). 5. I understand this discount only applies to my primary residence. 6. I may have to re-certify when transferring service or opening a new account. 7. Blue Topaz Utilities may share customer information with other utilities or agencies for enrollment in other assistance programs. 8. To opt-out of the program, I must call Blue Topaz Utilities at 936-756-7400. By submitting this application, I certify that the information I have provided in this application is true and correct. I acknowledge that I have read and understood the contents of this application. I also agree to the terms specified in NW Natural’s Residential Bill Discount Program (Schedule 330)
Signature:

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