Apply for the Bill Discount Program & Winter Shut Off Moratorium

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.

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

ZIP/Postal Code

Customer 14 Digit Account Number (without dash)

Household Information

*Total Number of Occupants

*Number of Adults

*Number of Children

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 Enter other… Gross Monthly Income (Before Taxes) Primary Source of Income Primary Source of Income Enter other…

*Total Gross Monthly Income for Entire Household (Before Taxes)

*Electronic Signature

Sign above

*Signature Date

NOTICE

Apply for the Bill Discount Program & Winter Shut Off Moratorium