PGE Income-Qualified Bill Discount Income Verification Form

Encrypted PGE Income Verification Form

All data on this form is encrypted for your security.

Your name(Required)

First Last

Phone

(###) ###-####

Your email(Required)

Enter Email Confirm Email

Your age

Your income

Your income source(s)

Number of people living in household(Required)

Please enter a number from 1 to 8.

Household member 2

Household member 2: Name

First Last

Household member 2: Age

Household member 2: Income Amount

Household member 2: Income Source(s)

Household member 3

Household member 3: Name

First Last

Household member 3: Age

Household member 3: Income amount

Household member 3: Income source(s)

Household member 4

Household member 4: Name

First Last

Household member 4: Age

Household member 4: Income amount

Household member 4: Income source(s)

Household member 5

Household member 5: Name

First Last

Household member 5: Age

Household member 5: Income amount

Household member 5: Income source(s)

Household member 6

Household member 6: Name

First Last

Household member 6: Age

Household member 6: Income Amount

Household member 6: Income source(s)

Household member 7

Household member 7: Name

First Last

Household member 7: Age

Household member 7: Income Amount

Household member 7: Income source(s)

Household member 8

Household member 8: Name

First Last

Household member 8: Age

Household member 8: Income amount

Household member 8: Income source(s)

Total income and file uploads

Please include every 18+ member of your household’s income amount (before taxes) and source, and provide documentation for each, for the last 30 days.

The definition of “gross (before taxes) household income” is all money and noncash benefits, available for living expenses, from all sources, both taxable and nontaxable, before deductions, for all people who live in the home. Examples of income documentation includes, but is not limited to the following:

Paycheck stubs
Unemployment verification letter, Social Security benefit award letter, TANF (Temporary Assistance for Needy Families) print out, Child Support print out, Proof of Veterans benefits, pensions, retirement, etc.
Written statement of Self-Employment detailing gross receipts and business expenses
Written statement with details of any additional cash income
If you have no income, please provide a written statement of how you sustain yourself financially, covering essentials like food and housing.

Total household income (calculated from amounts entered above)

File

Drop files here or

Max. file size: 16 MB, Max. files: 10.

Declaration:(Required)

I agree to inform PGE if my household no longer qualifies for the Income-Qualified Bill Discount.

True and correct:(Required)

I understand under penalty of perjury under the laws of the State of Oregon that the information I provided in this application is true and correct.

Signature(Required)

Phone

This field is for validation purposes and should be left unchanged.