Topics: Family law, Employment, Gross income Pages: 2 (755 words) Published: October 19, 2014
PECO Universal Services – Customer Assistance Program (CAP) Application INSTRUCTIONS: Please complete the application below. Attach proof of total gross income (before taxes) for each household member including yourself, and sign your name at the X. PLEASE COMPLETE ALL INFORMATION IN ORDER FOR THIS APPLICATION TO BE PROCESSED. (Please Print) 1. Enter your account number, home phone number, name, address, and cell phone number 2. Enter the name of all members of your household including yourself 3. Attach proof of gross household income for all members in your household including yourself There are four (4) ways to complete and submit your CAP application: 1. Mail the completed application along with the required proof of income to: PECO CAP, P.O. Box 16468, Pittsburgh, PA 15242-9945

2. Fax information to 1-866-362-8906 (Toll Free) (Note: you must include account number and name on every page) 3. On-line at - click “CAP” and then click “Apply” 4. E-mail –

You can receive CAP application updates via text message by checking the text message “check box” next to cell phone number below. Otherwise, you will be notified by mail. ACCOUNT NUMBER:

Home Phone:

NAME: Last


Middle Initial


Apt. Number



Cell Phone:

Zip Code
Check here to receive a status update via text message
Message & data rates may apply

See back of this application for acceptable sources of income List all the people who live with you, starting with yourself. Include all adults and children. Attach proof of all income for all household members including you. Attach additional sheet, if needed.

Name (Last, First, M.I.)

* Social Security #
or ITIN #

Birth Date


Source of Income
See back for sources


My signature on this CAP application gives my permission to PECO or its authorized agent to: (a) check any information I give about where I live, my jobs, income,...
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