Self-Certified Sensitive Online Form

SCE Customer Account Number (required) Example: 712345678901. The number should start with 7.

Customer Name (as it appears on your bill)

First Name (required)

Last Name (required)

Name of Self-Certified Sensitive Resident (if different)

First Name

Last Name

Service Account Number (required - Must be a valid 10-digit service account number starting with 8)

Service Address

Number (required)

Street (required)

Unit/Apt:

City (required)

Zip Code (required)

Telephone Number (required) Example: 123-456-7890

Check if Mobile Phone

Alternate Phone Example: 123-456-7890

Check if Mobile Phone

Email Address (required)

By completing this form, you are confirming that someone in the household has a condition that can be significantly affected by a disconnection and want to apply the sensitive self-certification status to the household.
The Self-Certified Sensitive status is valid for only one (1) year after processing.
The benefit to self-certification is that in the event of a disconnection of service for non-payment of your bill, we will attempt to reach you through your preferred method of contact (Email, Text, or Voice Call).
If we cannot reach you directly through your preferred method of contact, we will send a technician to your door to attempt to make in-person contact prior to the disconnection. Note: The status does not prevent a disconnection of service from occurring.

I certify that the above information is correct, and I understand the terms of self-certifying as Sensitive.

Signature (Type Customer Name) (required)

Date (required)