City of Alvin
Application for 100% Disabled Veteran’s Exemption for EMS Fees
GENERAL INSTRUCTIONS: This application is for use in claiming an exemption from the City of
Alvin EMS fee for account holders by a 100% Disabled Veteran with a service connected
disability. A qualified account holder is entitled to an exemption of one property the account holder
designates. This application applies to address of the account holder from the date of the
FILING INSTRUCTIONS: Each account holder must furnish all information and documentation
required by this application to determine whether the qualifications for the EMS fee exemption
have been met. This document and all supporting documentation must be filed with the City of
Alvin Utility Billing officelocated at 216 W. Sealy Street, Alvin, Texas, 77511. Do not file this
document with the County, or any other agency as it only relates to the City of Alvin Emergency
Medical Services department.
APPLICATION REQUIREMENTS: The completed application and supporting documents must
be submitted to the City of Alvin and is effective from the date of submittal. An application must
be submitted by the account holder who is a 100% disabled veteran with a rating designated as
such. A qualified account holder is entitled to the EMS fee waiver of one property the account
holder applicant owns or resides at. The exemption will apply to all members who have verification
that they reside at the address. The application is effective the day is it submitted and cannot be
retroactively backdated. For mailed in, emailed, and faxed applications, the date sent or submitted
shall be used as the application date. If that day is on a holiday, or a non-City business day, then
the date used for the application will be the next business day. The application must be furnished
with all information and documentation required so the City staff can determine whether the
exemption requirements have been met. This information must be submitted with the application
to the City of Alvin Utility Billing Department. Exemption forms that are incomplete must be
resubmitted. Missing, incomplete or inaccurate forms will delay the processing and a new date
will be used when all of the required documentation has been received. Once this exemption is
allowed, an application does not have to be filed again unless the account holder changes or the
qualifications for the exemption change.
DUTY TO NOTIFY: The City of Alvin may require a new application to be filed to confirm current
eligibility. If eligibility ends or changes, the account holder must notify the City of Alvin in writing
as soon as possible. The City may retroactively adjust the waiver in the event the account owner
fails to notify the City and the change has occurred for more than 30 days.
City of Alvin
Application for 100% Disabled Veteran’s Exemption for EMS Fees
SECTION 1: Property Owner/Applicant
Name of Account Holder ______________________________________________________________
Driver’s License, Personal I.D. Certificate or Social Security Number __________________________________
Physical Address, City, State, ZIP Code ______________________________________________________________
Phone Number (include area code) ______________________________________________________________
Email Address ______________________________________________________________
Mailing Address of Account Holder (if different): ______________________________________________________
Section 2: Type of Exemption and Qualifications
Veteran’s Name (account holder) ____________________________________________________________
Disability Rating (must be 100 to qualify) ______________________________ (attach letter)
Names of members residing at the address with the account holder:
SECTION 3: Certification and Signature
STATEMENT: If you make a false statement on this form, you could be found guilty of a Class A
misdemeanor or a state jail felony.
I, _____________________________________________ (printed name of account holder), swear or affirm
the following:
1. that each fact contained in this application is true and correct;
2. that the account holder identified in this application meets the qualifications; and
3. that I have read and understand the Notice Regarding Penalties for Making or Filing an
Application Containing a False Statement.
_____________________________________ ________________________
Signature of Account Holder or Authorized Representative Date
Submit to: City of Alvin or Email:
Utility Billing Department
216 W. Sealy Street Fax: 281-388-7215
Alvin, Texas 77511