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APPLICATION
Elderly Very Low Income Water & Sewer Discount
Applicant Name:
Mailing Address:
Phone Number:
Email Address:
Utility Acct #:
Utility Service Address (“Unit”):
Household Size: (total number of individuals residing at the service address)
All Other Residents: Name: Eligible Dependent: Yes / No
Name: Eligible Dependent: Yes / No
Name: Eligible Dependent: Yes / No
Name: Eligible Dependent: Yes / No
Please Note: Any individuals residing in the household that are NOT claimed as a dependent
will be required to submit a tax return, Form 1040, in order to verify total household income.
I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION AND ALL
ATTACHMENTS HERETO ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Applicant Signature: Date:
Please submit a complete application with the following attachments:
1. Copy of Government Issued Photo ID (ex: Drivers License, ID Card, Passport)
2. Income Verification (
all
household members)
US Federal Tax Return - Form 1040
3. If individually metered: A copy of most recent utility bill.
4. If Master Metered: A letter from the unit’s homeowners association (HOA) including
the following:
a. Confirmation that the Applicant is a resident of the above Unit and is the rate
payer of shared common expenses for the household.
b. The percentage used to calculate shared utility costs or shared common
expenses for the Unit per the Condominium Declaration.
c. Affirmation that the HOA will inform Town of any change in the residential
status of the Applicant or the percentage of interest used for shared expenses.
d. Affirmation that discount, if approved, will be passed on to the Applicant.
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Elderly Very Low Income Water & Sewer Discount Eligibility Requirements:
Pursuant to Town of Telluride Ordinance No. 1476 Series of 2019, a 50% discount on
water and wastewater service base rates is offered to Applicants meeting the following
criteria:
1. The Applicant is 65 or older, living in the residence, and is the rate payer of
water and wastewater services;
AND
2. The Applicant’s income does not exceed the Department of Housing and Urban
Development (HUD) Very Low Income threshold;
AND
3. The gross household income from any and all sources does not exceed the HUD
Very Low Income threshold;
AND
4. The Applicant’s submission demonstrating eligibility has been approved by the
Town of Telluride Finance Department.
Current Department of Housing and Urban Development Income Limits:
FY 2018 San Miguel County
Very Low Income
1 person
household
2 person
household
3 person
household
4 person
household
5 person
household
$ 29,750 $ 34,000 $ 38,250 $ 42,450 $ 45,850
NOTE: HUD Very Low Income Limits are updated annually in April. Discounts approved
are valid for the current calendar year only. Following initial approval, applications with
documentation verifying ongoing eligibility must be submitted on or before January 31
st
annually.
Complete applications including attachments may be submitted by:
Email: kjewett@telluride-co.gov
In-Person: 135 W. Columbia Ave., Telluride, CO 81435
Mon. Fri. (8am 5pm MST excluding holidays)
Mail: Town of Telluride
PO Box 397, Telluride, CO 81435
Attention (Utility Billing)
Official Use Only:
Received by:
Date: