Lompoc, CA · Santa Barbara County
Residential Medical Discount Program Application
Residential electric customers with qualifying medical needs use this application to request a lower-tier rate, with medical information certified by a physician.
What this form is
This application lets a Lompoc residential electric customer request a lower-tier rate for a qualifying full-time household resident who uses life-support equipment or needs special heating or cooling. The customer completes Part A, and a licensed M.D. or D.O. completes Part B. The application also offers optional third-party notification and must be renewed every two years.
Who needs it
A Lompoc residential electric customer may apply when a full-time household resident has a qualifying medical condition certified by a physician.
How to submit it
Mail the completed application to City of Lompoc, ATTN: Billing Dept, 100 Civic Center Plaza, Lompoc, CA 93436.
About notarization
This document is signed without a notary; the customer declares the application true and correct under penalty of perjury, and a licensed M.D. or D.O. certifies the medical information.
How to submit this form
- 1
Download The Application
Download the Residential Medical Discount Program Application.
- 2
Complete Part A
Enter customer, utility account, service, and patient information, then sign and date the customer agreement.
- 3
Request Physician Certification
Ask a licensed M.D. or D.O. to complete and sign Part B with the required medical information.
- 4
Complete Optional Notification
If desired, fill in the third-party notification section and obtain the requested signatures.
- 5
Mail The Application
Mail the completed application to the City of Lompoc Billing Department at 100 Civic Center Plaza, Lompoc, CA 93436.
Frequently asked questions
- Do I need a notary for the Residential Medical Discount Program Application?
- No. The customer signs a declaration under penalty of perjury, and a licensed M.D. or D.O. certifies the medical information; the document does not require a notary.
- Who can apply for the residential medical discount?
- A residential electric customer may apply if a full-time household resident regularly uses qualifying life-support equipment or has a physician-certified need for special heating or cooling.
- How do I submit the Residential Medical Discount Program Application?
- Complete Part A, have a licensed M.D. or D.O. complete Part B, and mail the application to the City of Lompoc Billing Department at the address shown on the form.
- Does the application include third-party notification?
- Yes. It includes an optional section to designate someone for notification of planned utility interruptions or scheduled disconnection for non-payment. That person is not obligated to pay your bill.