City of DuPont
LIFELINE PROGRAM
UTILITY DISCOUNT APPLICATION
LOW INCOME SENIOR OR LOW INCOME DISABLED
(Water Service)
If you qualify for the DuPont Lifeline Program, you may receive a 30% discount on basic
charges for water (up to 1,000 cf).
Name of Applicant Account No
Residence Address Phone No
Date of Birth Number in Household
Eligibility Criteria
□
Low income senior citizen (61 years of age or older)
(Please attach a copy of your tax return or other proof of income and proof of age.)
□
Low income disabled citizen
(Please attach a copy of your tax return or other proof of income and a Veterans
Administration or Social Security Administration proof of disability.)
□
Retired from regular, gainful employment due to a disability
Are you receiving:
Veterans’ Administration Disability Percent of Disability %
Social Security Administration Disability
To qualify for the Lifeline Program:
Applicant must be the sole occupant or head of household;
The utility account must be in the name of the applicant;
Applicant must be a permanent, year-round resident of the City of DuPont;
Applicant must reapply every 6 years to ensure they continue to meet the program criteria.
The applicant’s annual income must qualify them for a reduction from real or personal property taxes
as set forth by the Washington State Department of Revenue. As of January 2020, that disposable
income must not exceed $45,708 https://dor.wa.gov/content/property-tax-exemption-program-senior-
citizens-and-disabled-persons
I swear, under the penalties of either civil or criminal perjury, that I have read, understand, and meet all the
above criteria. I understand that if at any future date I no longer meet the criteria, it is my obligation to notify
the City of DuPont. I consent and agree that the City of DuPont may verify and confirm the above if deemed
necessary. The Social Security Administration and the Internal Revenue Service are authorized to release
any income information from their files.
Signature Date
City of DuPont
1700 Civic Drive
DuPont, Washington 98327
253-964-8121 phone
253-964-3554 fax
click to sign
signature
click to edit
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