S:\Ann\Water\Reduced Water - Sewer Rates\FY19-20\FY19-20 Reduced Rate Application.docx
2019-20 APPLICATION FOR REDUCTION OF CITY OF VENETA
UTILITY CHARGES FOR LOW INCOME RESIDENTS
You must re-apply each year to continue the reduction in your utility services.
Proof of income must accompany this form for processing
I (we) hereby request City of Veneta to reduce the Water & Sewer utility base fee based on the following information
(Please Print):
APPLICANT’S NAME: _____________________________________________________________
CO-APPLICANT’S NAME: __________________________________________________________
PHONE: ________________________________ SSN (last 4 digits): _______________________
SERVICE ADDRESS: ______________________________________________________________
(The property receiving service for which the reduction is sought must be applicant’s principal residence.)
MAILING ADDRESS: ______________________________________________________________
Other persons occupying the residence:
NAME
RELATIONSHIP
_________________________________________________ ________________________
_________________________________________________ ________________________
_________________________________________________ ________________________
In order to qualify, the maximum combined annual income for all persons residing at the residence must be at or below the income
for the size of household as listed on the back of this form. You must provide proof of your household monthly
income, and hereby consent to provide all information deemed necessary to make such determination. The applicant must submit
a copy of their most recent state and federal tax returns or Form SSA 1099 or other approval letter from a state or federal agency
qualifying them for such programs that are based on income.
If this application is approved, it shall become effective for the next billing period (no retroactive adjustments) and will be in effect
until June 30, 2020.
UNDER PENALTIES OF FALSE SWEARING, I/WE, THE UNDERSIGNED, STATE THAT THE FORGOING INFORMATION IS
TRUE AND CORRECT. I/WE FURTHER AGREE TO IMMEDIATELY NOTIFY THE CITY OF ANY CHANGE IN THE ABOVE
INFORMATION. BY SIGNING THIS FORM, I/WE AUTHORIZE THE RELEASE OF INFORMATION FROM THE LOW INCOME
ENERGY ASSISTANCE PROGRAM TO THE CITY OF VENETA FOR PURPOSES OF VERIFYING ELIGIBILITY.
_____________________________________________ ________________________
Applicant’s Signature Date
_____________________________________________ ________________________
Co-Applicant’s Signature Date:
RETURN TO: City of Veneta, Attn: Ann Frydendall
PO Box 458, Veneta, OR 97487
Phone: 541-935-2191
FOR CITY OF VENETA USE ONLY
Date & Approval By: ___________________ Entered By: ______ Date Entered__________ Act#: ______________
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
