City of Bainbridge Island
Low-Income Seniors/Low-Income Disabled Citizens
Fee Reduction Application
Select the fee reduction program you are applying for (check one):
APPLICANT NAME: _____________________________ _____________________________
(First) (Last)
Date of Birth: ____________________
SPOUSE/CO-TENANT: _____________________________ _____________________________
(First) (Last)
Date of Birth: ____________________
Service Address: _________________________________________
(Street Address)
Mailing Address: _________________________________________
(Street Address/ PO Box)
_________________________________________
(City/State/Zip)
Phone Number: _________________________________________
Total Gross Income for current year (include spouse’s or co-tenant’s income) from all sources: $___________________
Please provide:
A copy of last year’s Federal Income Tax Statement or a copy of Social Security Statement for income verification
purposes for applicant and spouse/co-tenant.
If applying for the vehicle license fee rebate, proof of payment of the $30 vehicle license fee.
Application for Water and Sewer Utility Discount
Persons age 61 or older who have a combined annual household income in an amount which would qualify them
for property tax exemption under RCW 84.36.381(5), which is currently $40,000, or low-income disabled
persons, may apply for the following discounts to their single-family residence utility bills:
WATER: 50% reduction
SEWER: 50% reduction
STORM DRAIN: 50% reduction
(BIMC 13.16.082 – 086, Ordinance No. 92-26, Resolution No. 2003-01)
Application for Vehicle License Fee Rebate
Bainbridge Island residents 18 years of age and older who have vehicles registered on Bainbridge Island and have
a car tab renewal date of August 1, 2019, or later with an annual household income at or below $40,000 as of
the monthly period prior to application are eligible to receive a $10 rebate in the form of a check after payment
for the vehicle license has been made.
(Resolution No. 2019-08)
By qualifying for these programs, applicants may also qualify for a discount on their SSWM fees and property taxes. Contact Kitsap
County for more information.
Revised 08/20/19
AFFIDAVIT: I swear under the penalties of either civil or criminal perjury that I have read the application form and
all of the statements, as marked, are true.
_____________________________________ _____________________________________
Applicant Signature Spouse/Co-Tenant Signature
Dated this ___________ day of __________________, 20 _____.
