Fillable Wcs Senior Application (City of Beaumont)

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Wcs Senior Application (City of Beaumont)

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SENIOR CITIZEN DISCOUNT RATE
Applicant meeting age requirement 65 or older may claim the Senior Citizen Discount rate exemption. Only one exemption
per person, residing in a single dwelling household, averaging on the first 1000 gallons on a monthly bill may be claimed.
*This application must be signed by applicant/spouse meeting the age requirement. Please complete this form and return
to the City of Beaumont, Water Department Customer Service Division, PO Box 3827, Beaumont, Texas 77704.
The property address ______________________________________ is my principal residence.
Name__________________________________________
Address_________________________________________
Telephone Number ( ) __________-___________
Date of Birth__________/___________/___________
Social Security__XXX - XX_ -___________
Spouse Name__________________________________________
Spouse Date of Birth_________/________/_________
Spouse Social Security __XXX - XX_ -___________
*Signature_________________________________________
*(Signature of Qualified Applicant Meeting Age Requirement)
Date_________/_______/________
cy/rt _________/___________ Account Number: ________________- _________________
Completed by in office staff Completed by in office staff
11//28/2017 bme
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Wcs Senior Application (City of Beaumont)

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Completed 15 July 2020

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