Please complete the following form to begin the registration process. Once your application has been submitted, a PGH2O Cares Representative will contact you within 2 business days. Information message *Required Fields Customer Information *Your Name *Your Phone Number Your Email Address I would like to add a second phone number and/or email address. Second Phone Number Second Email Address *Service Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Customer 7 Digit Account Number? Household Information *Total Number of Occupants *Total Number of Occupants - Select -12345678Other Enter number *Number of Adults *Number of Adults - Select -12345678Other Enter number *Number of Children *Number of Children - Select -012345678Other Enter number Income Information *For each occupant with income, please provide a name or nickname (such as adult 1, child 1, and so on), relationship to the main customer, their monthly income amount, and their primary source of income. The account holder's full name is required. *For each occupant with income, please provide a name or nickname (such as adult 1, child 1, and so on), relationship to the main customer, their monthly income amount, and their primary source of income. The account holder's full name is required. *Name or Nickname *Relationship Type *Relationship Type - Select -Account HolderFamily MemberPartnerRoommateOther… Enter other… *Gross Monthly Income (Before Taxes) *Primary Source of Income *Primary Source of Income - Select -Salary/WagesSocial Security (SSI or SSDI)Veteran’s BenefitsPensionDepartment of Welfare cash recurring benefitUnemploymentWorkman’s CompensationSelf-EmploymentRental IncomeRoyalties (such as gas drilling operations)InterestShort Term DisabilityLong Term DisabilitySpousal SupportChild SupportFoster Care/AdoptionOther… Enter other… *Total Gross Monthly Income for Entire Household (Before Taxes) Information Sharing *Is it ok for PWSA to share your contact and/or income information with other utilities in an effort to cross enroll customers in all available assistance programs? Yes No *Is it okay for PWSA to send you text messages and/or emails regarding updates to our Customer Assistance Programs and when it is time for you to recertify? Yes No Outreach Feedback *How did you hear about PWSA’s Customer Assistance Programs? *How did you hear about PWSA’s Customer Assistance Programs? - Select -PWSA Bill Insert/MailerPWSA Customer Service RepresentativePWSA EventDuquesne Light (directly or via Holy Family)Other Community Based OrganizationOther (please specify) Enter other… Lead Question Are you interested in applying or receiving more information about PWSA’s Lead Service Line Replacement Reimbursement Program? Yes No More information about the program is available at https://lead.pgh2o.com/leadreimbursement/. This program is free for income eligible customers. Please note: This program is only available to customers who receive water services from PWSA. A map of our water service area is available at https://www.pgh2o.com/your-water/learn-where-we-provide-our-services. *Electronic Signature Sign above *Signature Date CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.