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2. Application for Special Utility Rates and Services
   This form is used to evaluate requests for special utility service rates for low income senior citizens or disabled residents and for special non-curbside garbage pickups for customers whose physical conditions make it difficult for them to place the garbage container at the curbside location. Low income senior citizens and low income handicapped residents of the City may apply to receive water and sewer services at one quarter of the monthly minimum charge.

4. Water/Sewer Rate for Qualified Customers Water and sewer utility rates will apply to those qualified customers who live in the City of Snohomish (98290 Zip Code) and utilize a 5/8-inch single family residential service. Customers requiring service in excess of a 5/8-inch single family residential service shall not qualify for a rate reduction regardless of income.

6. Please use the following definitions in determining eligibility:

   (1)Low-Income: A household in which the gross annual income is below the very low income level for the Seattle/Everett area as established and amended by survey from time to time by the United States Department of Housing and Urban Development. Presently, the maximum income levels are set at the amounts below:

8. 
10. (2) Senior Citizen: A person 62 years of age or older whose income provides the primary financial resources for the household in which the citizen is a full time resident.
12. (3) Disabled: A citizen whose income provides the primary resources for the household in which the citizen is a full time resident and who has a physical impairment of such a nature as to materially affect the number and types of employment for which the individual can reasonably qualify. See Resolution 1312 for further definition.
16. Print this form and submit to City Hall with supporting documents.
18. First Name*
19. Last Name*
21. Email Address:*
23. Service Address (98290 zip code only)*
25. Account Number
27. Are you currently 62 years of age or older?*

    1. Yes
    2. No
29. Are you handicapped?

    1. Yes
    2. No
31. How many persons live in your household?*
    -- Select One --12345678
33. What was the household income for the past year?
    -- Select One --Below $38,750$38,751 - $44,300$44,301 - $49,850$49,851 - $55,350$55,351 - $59,800$59,801 - $64,250$64,251 - $68,650$68,651 - $73,100Above $73,100
35. List sources of income:
37. Do you anticipate major changes in household income during the current year? If yes, please explain:
39. I hereby swear and affirm under the penalty of perjury that the information on this application is true and correct to the best of my knowledge and belief.
41. Date
    Date
43. Phone Number
45. Required Supporting Documents

    Verification of income of household (Include full previous year income tax returns with related schedules & current social security benefit statement). If you do not filed taxes, please sign the below waiver and provide proof of all income received.

47. TAX WAIVER:

    I verify that I am not required and do not file a Federal Tax Return as specified by the Internal Revenue Service.

49. Documentation of disability (if appropriate)

51. Verification of age (Copy of driver's license, birth certificate, passport, etc..)
53. Upload Supporting Documents *

    Please upload copies of your supporting documents as listed above or provide photocopies in person or via mail at Snohomish City Hall, PO Box 1589, Snohomish, WA 98291

Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit Submit and Print

* indicates a required field