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NON PROFIT AGENCIES SERVING THE DISADVANTAGED - APPLICATION FOR DISCOUNTED UTILITY RATES

  1. Finance Department - Customer Service

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

  2. QUALIFICATION REQUIREMENTS

    To qualify for this discounted rate, the utility customer must meet the definition of a Non-Profit Agency, below:

  3. "Non-Profit Agency Serving the Disadvantaged" means agencies with a 501 (c) 3 tax exempt designation from the Internal Revenue Service (IRS) whose primary clients/customers qualify for the Low Income Senior Citizen Utility Rate or the low Income Disabled Citizen Utility Rate.

  4. My organization has a 501 (c) 3 status*

  5. Primary customers served are low income seniors and/or disabled citizens on the low income senior/disabled utility rate*

  6. AFFIDAVIT

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

  7. 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 check box to acknowledge.

  8. 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.

  9. FOR OFFICE USE ONLY

  10. Verified by clerk

  11. Leave This Blank:

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