UGI

UGI CAP Application
(Customer Assistance Program Application)

What type of energy does UGI provide to you?
Heating Account? Yes/No
*
Work Phone Home Phone

Household Members and Income - Indicate all sources of income for each household member (Income Amount represents gross monthly income). Please complete a section for each member of your household.

House Hold Member 1

Household Member 2

Household Member 3

Additional House Hold Members
List Name, SS#, Birthdate, M/F, Income Source(s), Income Amount(s) in the "Details" section, below:

Details

Household Expenses - Indicate all expenses for your household:
(Enter the number - for example if your Rent is $450.50 per month, enter 450.50)

Customer Assistance Program (CAP) CONSENT AND RELEASE

I agree and consent to UGI sharing the information contained in my application and all other information relating to my customer account with those employees, representatives, agents, contractors, or subcontractors of UGI utilitized to administer CAP and to evaluate my application for acceptance into CAP. Furthermore, I hereby release and hold harmless UGI, its employees, representatives, agents, contractors, and affiliates from and against any and all claims related to my application, my particiption in CAP, and the administration and evaluation of CAP.

Please check "Yes" below to acknowledge you have read and accepted the above consent.*

Customer Assistance Program (CAP) TRUTH OF STATEMENT

The information on this application is true and complete to the best of my knowledge. The employees, representatives, agents, contractors or subcontractors of UGI have the right to verify my income and expenses if necessary. I understand and accept that providing false or incomplete statements on this application will constitute cause for rejecting my application or removing me from CAP.

Please check "Yes" below to acknowledge you have read and accepted the above statement.*