FORM 998-B
Certification of Financial Hardship
CITY OF MANTECA UTILITY BILLING
THIS SECTION TO BE FILLED OUT BY ACCOUNT HOLDER
_____________________________________ ___________________________________________ Account Number Service Address
_____________________________________ ___________________________________________ Account Holder Name Number of Members in Household
_____________________________________ ___________________________________________ Date of Bill seeking Payment Arrangement Amount of Bill Seeking Payment Arrangement
1. Which of the following forms of assistance are currently utilized by the household? (Only one member of the household need to provide proof of assistance to complete this form.) Assistance Recipient Name Proof Required
Medi-Cal Notice of Action from SJ Co
Human Services Dept
Ca1works Social Security Benefit
Verification Letter
CalFresh Notice of Action from SJ Co
Human Services Dept
General Assistance Notice of Action from SJ Co
Human Services Dept
WIC WIC Card + Valid California ID
(None) Declaration of Household
Income – Form 998-B2
2. Certificate of Financial Hardship
I, the udersigned, declare under penalty of perjury under the laws of the State of California that I am the recipient of the above-indicated assistance, that I have provided proof of this, and that I am a member of household of the service address indicated above.
_________________________________ _______________________________________ Recipient Name Account Holder Name
THIS SECTION TO BE FILLED OUT BY CITY STAFF
ATTACHMENT 4