Residential Affordability Discount Program Form

Penalties for Fraud:

Whoever obtains or attempts to obtain program enrollment for which he or she is not entitled, by means of willful false statements or other fraudulent means, may be considered guilty of a criminal offense and upon conviction may be fined and/or imprisoned.

Please read and click each box below:

I certify that the information for the income of all household members 18 years and older is true and correct to the best of my knowledge and belief. I understand that the information will be verified to the extent possible; and that I may be subject to prosecution for providing false or fraudulent information. Please check box below.

Yes

I have read and acknowledge the general eligibility requirements to participate in the Affordability Discount Program. I understand that submitting this application does not automatically enroll me in the Affordability Discount Program, and that the information I have submitted must be verified and approved prior to enrollment. Please check box below.

Yes

By submission of this application, I hereby authorize CPS Energy to release all enclosed application information to other non-profit agencies and/or government entities (e.g. Bexar County, City of San Antonio etc) offering programs for the benefit of the resident or the home. (e.g., thermostat, minor repairs, energy and water efficiency, generation, conservation or community support services).

Electronic Signature

Type your full name here.

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