Residential customers who meet certain qualifications and are deemed to be indigent (suffering from extreme poverty) may complete an Affidavit for Indigence.
The customer is financially unable to pay their City of Modesto utility bill within the normal billing cycle by demonstrating they or a member of their household is a current recipient of one of the following assistance programs: CalWorks, CalFresh, General Assistance, Medi-Cal, Supplemental Security Income (SSI), State Supplementary Payments (SSP), California Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The customer demonstrates their household income is less than 200% of the federal poverty level.
Eligible applicant is the City of Modesto utility account holder or a member of their household.
Eligible applicants must be a current recipient of a qualifying assistance program.
Documentation confirming benefits from the public assistance agency is required.
Please provide proof of enrollment in a qualifying assistance program. Do not include any confidential information such as a social security number.
I understand by checking the box and submitting this form I am giving my electronic signature.
This field is not part of the form submission.
* indicates a required field