MEDICAL BASELINE ALLOWANCE

MEDICAL BASELINE ALLOWANCEINFORMATION & APPLICATIONWhat is Medical Baseline Allowance?The Medical Baseline Allowance program providesadditional natural gas for SoCalGas customers withcertain medical conditions. It is not a discount or rebate.Customers on this program will receive 0.822 additionaltherms per day, billed at our lowest baseline rate.QualificationsTo qualify, you or a full-time resident of your homemust require additional heat due to a qualifying medicalcondition. For example, you may qualify if a residentof your home has paraplegia, quadriplegia, hemiplegia,multiple sclerosis, scleroderma, a compromised immunesystem or a life threatening illness. Eligibility is NOTbased on income.What if I pay my landlord for my natural gas?You may qualify for Medical Baseline Allowance even ifyour landlord bills you for your natural gas. The landlordwill reflect the allowance on your billing statement. 2020 Southern California Gas Company. All copyright and trademark rights reserved.PAGE 1 OF 10FORM 4859E LRG FNT N20E0245A 1120

MEDICAL BASELINE ALLOWANCE INFORMATIONHow do I apply?To apply, complete Part 1 of the attached application.Next, have a medical provider complete Part 2 of theapplication, certifying the need for additional heat due tothe medical condition. Medical providers include licensedmedical doctors [M.D.], doctors of osteopathy [D.O.],nurse practitioners [N.P.] or physician’s assistants [P.A.]).We accept e-signatures from medical providers. Don’tforget to make a copy for your files.Mail the completed application to:SoCalGasMedical BaselineAllowance ProgramM. L. GT19A1P.O. Box 513249Los Angeles, CA 90051-1249Fax: 213-244-4665Once we receive your application, we will review theinformation. If you qualify, you will see the additionalallowance on your bill. Please allow one full billing cyclefor the change. If you move, you must notify SoCalGas so that your allowance can be transferred to your newaddress. Providing assistance to customers with specialneeds is just one way we strive to keep natural gasaffordable.PAGE 2 OF 10

MEDICAL BASELINE ALLOWANCE INFORMATIONWhat if I need assistance?If you need assistance after hours in a language otherthan English or Spanish, please call our LanguageInterpreter Service Line at 1-888-427-1345.Hearing impaired customers who are unable to use aconventional telephone can call us toll free at1-800-252-0259 (available in English and Spanish only).You can also request a large-print or Braille bill bycalling 1-800-427-2200.For more informationPlease visit socalgas.com/Medicalor call 1-800-427-2200.Para una solicitud de Asignación Médica Inicial enespañol, por favor llame al 27-14291-800-427-0478Please keep a completed copy of the application for your records.socalgas.comPAGE 3 OF 101 (800) 427-2200

APPLICATION FOR ENROLLMENTAND RE-CERTIFICATIONPART 1: To be completed by customer (please print)ACCOUNT NUMBER(Please provide your SoCalGas Customer account number)CUSTOMER NAME (First and last as it appears on your bill)MEDICAL BASELINE RESIDENT’S NAME (if different)SERVICE ADDRESSAPT/SPACE #CITYCUSTOMER MAILING ADDRESS (if different)CITYPRIMARY PHONE--ALTERNATE PHONE-(Continued next page)PAGE 4 OF 10

MEDICAL BASELINE ALLOWANCE APPLICATIONFor customers billed by someone other than SoCalGas:NAME OF MOBILE HOME OR APARTMENT COMPLEXCOMPLEX ADDRESSCOMPLEX MANAGER’S NAMECOMPLEX PHONE--NAME OF TENANTTENANT’S PHONE--(Continued next page)PAGE 5 OF 10

MEDICAL BASELINE ALLOWANCE APPLICATIONI UNDERSTAND THAT:1If the medical provider certifies that the resident’smedical condition is permanent, SoCalGas will requirecompletion of a form self-certifying continued resident’seligibility for Medical Baseline Allowance every two years.If the medical provider certifies that the resident’smedical condition is not permanent, SoCalGas will requirecompletion of a form self-certifying continued resident’seligibility for Medical Baseline Allowance each year andcompletion of a new application with a medical provider’scertification every two years.If the resident has a vision disability, the resident maycontact SoCalGas to request special notification wheneither re-certification (to complete a new application witha medical provider’s certification) or self-certification formsare mailed.SoCalGas cannot guarantee uninterrupted natural gasservice, and the resident is responsible for makingalternate arrangements in the event of a natural gasoutage.(Continued next page)PAGE 6 OF 10

MEDICAL BASELINE ALLOWANCE APPLICATIONI certify that the above information is correct. I also certify theMedical Baseline Allowance resident lives full-timeat this address, and requires or continues to require themedical baseline allowance. I agree to allow SoCalGasto verify this information. I also agree to promptly notifySoCalGas if the qualified resident moves or medicalbaseline allowance is no longer needed by the resident.How would you like to be contacted in case of a plannedor rotating outage?c Call me at the number belowc Send me a text message at the number belowc Contact me by TDD/TTY at the number belowc Email me at the address belowNUMBER OR EMAIL:SIGNATURE:DATE:X//The standard medical baseline allowance is 0.822 therms of natural gas perday, which is in addition to your daily standard baseline allocation. If thisallowance does not meet your medical needs, please contact SoCalGas at1-800-427-2200 to discuss additional amounts. Hearing impairedcustomers who are unable to use a conventional telephone can call us tollfree at 1-800-252-0259 (available in English and Spanish only).(Continued next page)PAGE 7 OF 10

MEDICAL BASELINE ALLOWANCE APPLICATIONPART 2: To be completed by a medical provider (licensedmedical doctor [M.D.], doctor of osteopathy [D.O.], nursepractitioner [N.P.] or physician’s assistant [P.A.])I certify that the medical condition and needs of my patientPatient’s Last Name (please print):Patient’s First Name (please print):1. Requires use of a life-support device* (check one)c Yes c NoThe following life-support device(s) is(are) used in the above-namedpatient’s home:Device:c Electricityc Natural gasc Electricityc Natural gasc Electricityc Natural gasDevice:Device:*Qualifying life-support equipment is any device which usesmechanical or artificial means to sustain, restore, or supplant a vitalfunction. The device must run on natural gas supplied by SoCalGas.Devices used for therapy rather than life-support, such as pools andspas, do not qualify.PAGE 8 OF 10(Continued next page)

MEDICAL BASELINE ALLOWANCE APPLICATION2. Requires heating and cooling:Standard Medical Baseline Allowances are available forheating if patient is paraplegic, quadriplegic, hemiplegic, hasmultiple sclerosis or scleroderma. Standard Medical BaselineAllowances are also available if patient has a compromisedimmune system, life threatening illness, or any othercondition for which additional heating is medicallynecessary to sustain the person’s life or preventdeterioration of the person’s medical condition.Requires standard Medical Baseline Allowance for heating:(check one) c Yes c No3. I certify that the life-support device(s) and/oradditional heating will be required for approximately:(check one) c No. of Years or c PermanentlyMEDICAL PROVIDER’S NAME:PHONE NO.:--OFFICE ADDRESS:M.D./D.O./N.P./P.A. STATE LICENSE OR MILITARY LICENSE NUMBER:MEDICAL PROVIDER’S SIGNATURE:XDATE://PAGE 9 OF 10(Continued next page)

MEDICAL BASELINE ALLOWANCE APPLICATIONFOR SOCALGAS USE ONLYDate Received:Recertification:Medical Baseline Allocation:Electric unit(s):c Self-certify every two yearsc Self-certify annually; medical provider’s certification every two yearsMAIL APPLICATION TO:SoCalGasMedical Baseline Allowance ProgramM. L. GT19A1P.O. Box 513249Los Angeles, CA 90051-1249Fax: 213-244-4665PAGE 10 OF 10Gas unit(s):

The standard medical baseline allowance is 0.822 therms of natural gas per day, which is in addition to your daily standard baseline allocation. If this allowance does not meet your medical needs, please contact SoCalGas at 1-800-427-2200 to discuss additional amounts. Hearing impaired