PGE Income-Qualified Discount Application

Use this form for your initial application or to update your information if your household size or income changes.
Contact information for person submitting the application*

Your NameLast Name
Phone number*
Please enter a valid phone number.
Email
example@example.com
Relationship to customer
If other, please specify:
Please note: After reviewing the application, we will reach out directly to the PGE account holder regarding their enrollment status.
PGE account holder information
Primary name on your PGE bill*

First NameLast Name
PGE account number (10-digits)*
You'll find your 10-digit PGE account number in the upper right corner of your PGE bill or by logging into your account online.
Service address (primary residence)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred phone number
Please enter a valid phone number.
Email
example@example.com
Preferred language *
Our Customer Service Advisors can assist you in 200+ languages. You can also apply by giving us a call at 503-228-6322.
If other, please specify:
Does someone in your household have medical needs that require electricity?*

YesNo
The Medical Certificate Program can offer additional support for those who qualify. Please visit the Medical Certificate Program website to learn more or give us a call at 503-612-3838 to go over details and start the enrollment process.
Household and income information

Your discount will depend on your household size and your household’s average gross annual income (before taxes).
Household size (all members including adults and children)*
Need help calculating your annual household income?

Yes, I would like some guidanceNo, I'm good
Total gross household income includes all taxable and nontaxable revenues from all adults (18+) living in the home, from all sources, including but not limited to wages, salaries, unemployment, interest, dividends, spousal and child support payments, Social Security and Social Security Disability, pensions, rental income and net income from self-employment (energy assistance should not be included your income calculation).

• For hourly workers, take your hourly wage and multiply that by the average hours worked
weekly

• Multiply that number by 52 (weeks per year) to get your annual gross income

Example:
• $13.50 (hourly rate) x 40 (average hours worked per week) = $540

• $540 x 52 (weeks per year) = $28,080 (This is your annual gross income)

In case your household income changes from month to month, take your combined income from the last month and multiply it by 12 to calculate your average gross annual household income.

If you have questions about how to calculate your income, or what is considered
income, give us a call at 503-228-6322.
Average gross annual income of your household (before taxes)*
Annual income (12 months)
I confirm this is my annual income (12 months).*

Yes
I am currently on a fixed income and receive income or benefits from one or more of the following: Social Security, SSP or SSDI, interest/dividends from retirement accounts, Medicaid or SSI.

YesNo
The following question is optional and doesn't affect your eligibility — it's to help us make sure we're serving everyone equitably. How would you best describe yourself?
If other, please specify:
Declaration
1. I understand this is an initial application and PGE will follow up with me after formal enrollment with details regarding my discount.
2. I will notify PGE if my average annual gross income or household size changes by submitting a new application online or by calling PGE (503-228-6322) so my information can be updated.
3. I understand I may be required to provide proof of household income and household size if asked. Information will be made available to PGE and persons or entities working on behalf of PGE to implement this program.
4. I understand this discount will not apply to my previous charges, but only new charges billed after enrollment (enrollment may take up to 30 days) and not to the total amount due on the bill. Certain charges are not included in this discount.

By signing this declaration, I certify that the information I have provided in this application is true and correct. I acknowledge that I have read and understood the contents of this application. I also agree to the terms and conditions specified in the PGE Income-Qualified Bill Discount Tariff.
I have reviewed the program details and conditions and shared the information with the PGE account holder listed above, including that by participating in the program, the applicant understands their income may be subject to review by PGE or those working with PGE on the implementation of this program. Failure by the applicant to provide requested information during an income review may result in the applicant being withdrawn from the program.

By signing below, I swear and affirm I have been authorized by the PGE account holder listed on this application to complete the application on their behalf. Should the account holder at any time deny I have been authorized to prepare this application, the account holder can be unenrolled.
Electronic signature
Please enter your full name*
Enter full name of preparer*
Should be Empty:

PGE account holder information

Household and income information

Declaration

Electronic signature