Fillable PUD DISCOUNT APPLICATION

Fill Online, Printable, Fillable, Blank PUD DISCOUNT APPLICATION Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

PUD DISCOUNT APPLICATION

On average this form takes 15 minutes to complete

The PUD DISCOUNT APPLICATION form is 2 pages long and contains:

  • 0 signatures
  • 5 check-boxes
  • 59 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
HOUSEHOLD OCCUPANTS/MEMBERS
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 income. (Attach an additional page if
needed.) If Applicable, list names the same as they appear on DSHS paperwork.
ACCOUNT HOLDER & ADULT OCCUPANTS 19 YEARS OLD AND OVER:
Full Name Date of Birth Relationship to Account Holder Monthly Gross Earned
(enter below) MM/DD/YY (enter below) & Unearned Income
Self (Account holder) $
$
$
CHILD/YOUTH OCCUPANTS 18 YEARS OLD AND UNDER:
Full Name Date of Birth Relationship to Account Holder
Monthly Unearned Income
(enter below) MM/DD/YY (enter below) (e.g., SSI, Tribal, VA)
$
$
$
TOTAL INCOME: $
*If Applicable, list account holder’s name the same as it appears on DSHS paperwork
DSHS Food Benets (SNAP)? o Yes o No
If “Yes,” provide (check one) o DSHS Client ID or o SSN for verification of your income and household size:
If additional members of your household qualify, complete the following specific information for all applicable
members (attach additional page if necessary):
Name: o DSHS Client ID or o SSN
Name: o DSHS Client ID or o SSN
Name: o DSHS Client ID or o SSN
PLEASE COMPLETE THE “EXPENSES” SECTION ON THE BACK BEFORE SIGNING YOUR APPLICATION.
INCOME DOCUMENTATION REQUIREMENTS
Provide documentation for the previous three full months of income for all people in the home. Types of
documentation include, but are not limited to: pay stubs, award letters, complete bank statements, annual Social
Security or retirement statements, annual tax returns (provide all pages, originals will not be returned). Self-
employed customers must submit previous year’s 1040 and Schedule C.
PUD DISCOUNT APPLICATION
2350 3/21
***INCOMPLETE APPLICATIONS OR MISSING DOCUMENTATION WILL DELAY PROCESSING***
SEE OTHER SIDE FOR INCOME ELIGIBILITY
ACCOUNT HOLDER’S NAME (please print entire name*)
ADDRESS OF ELECTRIC/WATER SERVICE (include City and Zip Code)
SECONDARY TELEPHONE NUMBER
( )
o Home land-line o Mobile
FOR SNOHOMISH COUNTY PUD USE ONLY
ACCOUNT HOLDER’S NAME ACCOUNT # BILLING CYCLE RECEIVED BY/DATE APPROVED % DENIAL CODE
Esta aplicación está disponible en español en nuestro sitio web www.snopud.com/discounts
(Continue on other side)
EMAIL ADDRESS
PRIMARY TELEPHONE NUMBER
( )
o Home land-line o Mobile
> PLEASE USE ONLY BLACK OR BLUE INK
MAIL this completed and signed application, along with required documentation, TO:
PUD Discount Service Center — PO Box 1107, Everett, WA 98206-1107. Or FAX TO: 425-267- 6137.
QUESTIONS:
www.snopud.com/discounts, 425-783-1000 (toll-free in Western Washington and
outside the Everett local calling area at 1-877-783-1000), Monday through Friday, 8:00  to 5:30 
SIGNATURE OF ACCOUNT HOLDER DATE
X
INCOME TYPES
Previous three months of documentation required for sources of all income, including, but not limited to:
w Wages, Tips & Salaries (not needed for minors)
w Self-Employment Income (not needed for minors and do not deduct depreciation or losses)
w Social Security and Other Retirement Benefits (e.g., pensions, annuities)
w SSI or Disability Payments
w Tribal Per Capita
w Child or Spousal Support, including: foster care, alimony, adoption support, separate maintenance payments received
w Veterans Benefits
w Unemployment Benefits
w All other income for adult occupants
Note: Student financial aid is not counted as income.
EXPENSES
List your expenses and explain what and how much assistance (e.g., student financial aid, loans, cash gifts, savings, etc.) you
receive to help meet your basic living needs.
Monthly Amount Where did the funds come from?
Electricity/Gas/Utilities: $
Transportation: $
Food: $
Rent/Mortgage: $
Do you currently receive housing assistance? o Yes o No
Other: $
INCOME ELIGIBILITY (Maximum after deduction)
Monthly Annual
Household Size: 1 person ............................................$2,521 $30,252
2 people .............................................$2,903 $34,840
3 people .............................................$3,660 $43,920
4 people .............................................$4,417 $53,000
Each Additional Person, ADD: .......$756 OR $9,080
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 the PUD of signicant changes to income and/or
number of occupants. Audits of discounts may occur at any time. I grant permission to Snohomish County PUD and other government
agencies in possession of my personal data, including but not limited to nancial and account information, to request or release my
data when necessary to establish, verify, or monitor eligibility, make payments on my behalf, or for other purposes in connection with
my receipt of benets.
o I would like to be considered for future Income-Qualified Energy Efficiency/Conservation Assistance Programs.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

PUD DISCOUNT APPLICATION

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 7 February 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document