Date of Birth
Income Type Gross Earned &
CITY OF BREMERTON DISCOUNT APPLICATION
***INCOMPLETE APPLICATIONS OR MISSING DOCUMENTATION WILL DELAY PROCESSING***
UTILITY BILLING • 345 6TH ST., STE. 100 • BREMERTON, WA 98337-1891 • PH: 360-473-5316 • FX: 360-473-2330 • firstname.lastname@example.org
List all household occupants. An occupant is anyone who lives in the home, whether a relative or not. Even if the person
does not pay rent, you must list him/her as an occupant and include below. If applicable, list the names the same as
they appear on SSA/SSI paperwork.
INCOME TYPES AND DOCUMENTS REQUIRED
MAILING ADDRESS (include City and Zip Code)
If you do not have proof of income or you did not work, you must submit one of the following documents:
• Proof of lack of income. Visit the IRS website: and complete the “Verication of Non-ling” for 2020 and submit to the IRS. When you receive the
report from the IRS attach a copy to the application.
• A letter explaining your circumstances. We may request more information or supporting documentation.
• Wages, Tips & Salaries – four (4) pay stubs
• Self-Employment Income – previous year’s tax return
• Social Security & Other Retirement Benets – SSA award letter &/or
previous year tax return (over 62)
• SSI or Disability Payments – SSI award letter or bank statement
• Child or Spousal Support – court documents
• Rental Income or Partnerships – need a letter of self certicate
• Withdrawals or Dividends – previous year tax form
• Unemployment Benets – unemployment award letter
• Workers Compensation (L&I) – a pay stub
• Annuities – W-2
• Copy of Photo ID
FOR CITY OF BREMERTON USE ONLY
SR / DIS / LIQ / NQ
ACCOUNT HOLDER’S NAME
(SEE OTHER SIDE)
BREMERTON CITY LIMITS DISCOUNT
Qualifying service locations within Bremerton city limits will receive a discount with Waste Management.
Applying for Bremerton city limits cable discount?
By signing this agreement I certify that the information on this form is true and correct and that false or incorrect information will result in denial or immediate removal of
discount(s). I also agree to the following: I will notify Utility Billing of signicant changes to income and/or number of occupants. Audits of discounts may occur at any time.
SIGNATURE OF ACCOUNT HOLDER