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Low Income Gas Rate Application

Yes! I would like to apply for Columbia Gas's Discount Rate program.  By submitting this form, I authorize the agency responsible for qualifying me for benefits being received to release information on this application to Columbia gas of Massachusetts.  I authorize the administrator of the program checked to notify the company in the event that my benefits are terminated.  I also understand that I must notify Columbia Gas if my benefits are discontinued.  By submitting this form, I certify all information provided to be true.

* Denotes Required Fields
Account Number *
Phone Number *   ( ) -
First Name *    
Last Name *    
Email *    
Address *    
City *    
State *  
Zip *    

** Requires acceptance letter from the certifying agency