I certify that the above information is correct. I also certify that the qualifying resident lives full-time at this address and requires or continues to require the Medical Baseline Allowance. I agree to allow SDG&E to verify this information. I also agree to promptly notify SDG&E if the qualified resident moves or the Medical Baseline Allowance is no longer needed by the resident. By signing below, I authorize SDG&E to share my customer information with other utilities and/or their agents to enable them to enroll me in other utility assistance programs.
I also authorize SDG&E to share my information regarding my participation in SDG&E’s Medical Baseline Allowance Program, including, without limitation, my name, address, contact information, circuit data, Medical Baseline Allowance Program enrollment status and medical equipment needs as described in this form if requested by emergency services professionals and agencies at the city, county, state and federal level for the purposes of managing de-energizations and to allow such parties to plan for and manage emergency situations.