Fillable PUBLIC SERVICE AUTHORITY DISABILITY DISCOUNT FORM (County of Henry)

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PUBLIC SERVICE AUTHORITY DISABILITY DISCOUNT FORM (County of Henry)

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BROWSE COUNTY OF HENRY (VA) FORMS

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PUBLIC SERVICE AUTHORITY
DISABILITY
DISCOUNT FORM
______________________________ ___________________
NAME PSA ACCOUNT NO.
          SERVICE ADDRESS
I hereby certify that I am disabled and that I am the owner or leasee of
the property described above.
__________________________________ ____________________
SIGNATURE DATE
PUBLIC SERVICE AUTHORITY USE
USER (__water,__sewer,__both)
NON-USER (__water,__sewer,__both)
Identification provided:
Social Security Disability Letter
Insurance Disability Certificate
BBBBBBBBBBBBBBBBBBBBBBBBB
VERIFIED
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PUBLIC SERVICE AUTHORITY DISABILITY DISCOUNT FORM (County of Henry)

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Completed 17 July 2020

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