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Customer Assistance Application

Customer Assistance Application

Household Members and Income


Indicate all sources of income for each household member (Income Amount represents gross monthly income). Please complete a section for each member of your household.

Household Member 1

Household Member 2

Household Member 3

Additional Household Members

Household Expenses


Indicate all expenses for your household.
(Enter the number - for example if your Rent is $450.50 per month, enter 450.50)

Customer Assistance Program (CAP) Consent and Release


I agree and consent to UGI sharing the information contained in my application and all other information relating to my customer account with those employees, representatives, agents, contractors, or subcontractors of UGI utilized to administer CAP and to evaluate my application for acceptance into CAP. Furthermore, I hereby release and hold harmless UGI, its employees, representatives, agents, contractors, and affiliates from and against any and all claims related to my application, my participation in CAP, and the administration and evaluation of CAP.

Customer Assistance Program (CAP) Truth of Statement


The information on this application is true and complete to the best of my knowledge. The employees, representatives, agents, contractors or subcontractors of UGI have the right to verify my income and expenses if necessary. I understand and accept that providing false or incomplete statements on this application will constitute cause for rejecting my application or removing me from CAP.

Please allow up to 5 business days for us to process your request.