Fillable Senior-Reduced-Utility-Rate-PDF 2019 Reduced utility rate application.1xlsx (kw edits 3-22-18).xlsx

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Senior-Reduced-Utility-Rate-PDF 2019 Reduced utility rate application.1xlsx (kw edits 3-22-18).xlsx

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File type: PDF

U.S.A. forms for City of Arlington Washington

BROWSE CITY OF ARLINGTON WASHINGTON (WA) FORMS

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Name (Please Print):
Mail Address:
Please answer the following questions:
Yes No
Did
or will you file a federal tax return for 2018?
If YES, include a full copy of your most current tax return including all schedules.
Yes No
Yes No
*
*
Disability:SocialSecurityAdministrationorVADetermination
State:__________
INTERNALUSEONLY:
Disability:(Circle) PermanentorTemporary
DisabilityExpirationdate:________________StaffInitials:________________________
DateReceived:______________________
Are you a renter? If you are a renter and eligible for this program, by signing this application you certify
that you are responsible for paying the water bill; Or your rent has been reduced by the amount of the
rate reduction.
Proofofageanddisability(ifapplicable)isrequiredwitheachapplication.Documentationcouldinclude:
ForAge:Driver'slicense,BirthCertificate,Passport,orOther
Temporary
Zip:____________ Phone:_______________________
If NO, include documentation to support income
, such as social security statement, W-2 or 1099's.
And, you must also include November and December bank statements for the most current year
for all bank accounts and/or retirement accounts.
Is there any other person living into the home who contributes to household expense? If so, provide tax
return or other supporting documentation (as stated above) for each member, and include all income in
the "INCOME FOR HOUSEHOLD" column on the next page.
2019 City of Arlington Application for Reduced Utility Rates
The City of Arlington offers reduced rates to qualified low income seniors and disabled customers for water, sewer, and
storm-water provided by the City. The program includes both homeowners and renters who live in a primary residence
receiving a separate Arlington water and/or sewer bill for service.
EligibilityRequirement
SnohomishCounty,Final2018Lowincomeyearlylimitsarelistedbelow: NumberofFamilyMembers ________
1‐Person$37,450;2‐Person$42,800;3‐Person$48,150;4‐Person$53,5005‐Person$57,800;6‐Person$62,100
7‐Person$66,350;8‐Person$70,650
ApplicationInformation
City: ______________
Please check one:
Disability Senior
**Disability is (please check one):
Permanent
Name of Applicant:
Street Address:
$
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$
*
* Declare under penalty of perjury that the information in this application is true and complete.
*
*
Date:_______________
Social Security or Railroad Retirement
VA Benefits
Military Pay and Benefits
2019 City of Arlington Application for Reduced Utility Rates
Interest (all sources)
Dividends
Alimony/Child Support
Gross Business Income (exclude losses and expenses)
Wages, Salaries, Tips, etc.
Gross Income Verification
Number of household members included in income verification:_______
Income For Household*
Birthdate:
If I receive reduced rates without meeting the qualification guidelines, I will be required to pay back the discount
received.
Income Source
*Include "gross income", as defined by 26 USC 31 for all household members.
Certification
By signing this form I confirm that I:
Have provided all documentation to verify household income and will provide additional documentation upon
request.
Capital Gain (exclude losses)
Other Gains
Pensions and Annuities
Rental Income (exclude depreciation and expenses)
Real Estate Income (exclude depreciation and expenses)
Total Number in Household:_________
Understand it is my responsibility to notify the City if I move, sell or transfer interest in my property, no longer
receive disability payments, or income no longer qualifies.
IRA Distributions
Royalties
Farm Income
Unemployment
All other Income
TOTAL INCOME
$
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Completed 10 July 2020

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