S:\Ann\Water\Reduced Water - Sewer Rates\FY20-21\FY20-21 Reduced Rate Application.docx
2020-21 Application for Reduced Utility Charges
for Low Income Residents
You must re-apply each year to receive the reduced rate.
Proof of income MUST accompany this form
I (we) hereby request City of Veneta to review my application for reduced water & sewer base fees:
(Please Print):
APPLICANT’S NAME: _______________________________________________________________
CO-APPLICANT’S NAME: ____________________________________________________________
PHONE: ________________________________ SSN (last 4 digits): _______________________
SERVICE ADDRESS: ________________________________________________________________
(The property receiving rate reduction 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 18 and over residing at the residence must be at or below
the income for the size of household as listed on the back of this form. Please fill out both sides of the application.
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, 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, 2021.
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 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
Approval By: __________ Entered By: __________ Date Entered: _________________ Act#: _________________
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