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LOW INCOME DISABLED CITIZEN SPECIAL UTILITY RATE APPLICATION

  1. Finance Department - Customer Service

    501 N. Anderson, Ellensburg, WA 98926 Phone: (509) 962-7201 Fax: (509) 962-7130

  2. INFORMATION

    FILING PERIOD. The application for special rate must be filed annually with the City Utilities Office prior to November 1st each year. If approved utility discounts will be valid January 1st thru December 31st each year. Any filing of a valid application after November 1st of any year shall apply only; after approval, to utility statements mailed after the date of approval and shall not be retroactive to any billing statements prior to approval.

  3. I own or rent my place of residence and the utility account is in my name*

  4. I reside in federally subsidized housing*

  5. My disability is marked below. *

  6. Start Service Requirements

    A customer service representative must be able to contact you prior to starting utility service to: 1) get confirmation of your identity (usually your social security number and driver's license number); and 2) documentation of disability from the Social Security Administration; 3) a copy of the special parking privilege card issued by the department of licensing; or 4) other documentation from a qualified medical professional of the following marked disability.

  7. Before utility service starts, I will...*

    Select one of the following

  8. TOTAL INCOME FOR ALL SOURCES FOR 2017

  9. AFFIDAVIT*

    I hereby swear under penalties of perjury that I understand the questions on the application and that all of the statements, as marked, are true.

  10. Electronic Signature Option

    NOTE: If submitting this form electronically, please type your name and date on the corresponding lines above. Please review the electronic submittal disclaimer, and initial box to acknowledge.

  11. ELECTRONIC SUBMITTAL

    By placing your typed initials in the box, typing your name and date in the applicant/citizen signature field, and submitting this form electronically, I CERTIFY that all the information I am providing on this form is true and correct to the best of my knowledge. I also understand that my electronic signature is legally binding as if I were physically signing the form. I understand that any material misrepresentation, omission or falsehood may result in rejection or nullification of my application.

  12. This claim is subject to audit by the City of Ellensburg. A random verification of income will be made.

  13. FOR OFFICE USE ONLY

  14. Leave This Blank:

  15. This field is not part of the form submission.