·  

GENERAL

INSTRUCTIONS

Eligible applicants for this program will have the late penalty

charge waived on Electric and Water Utility bills.  To be eligible:

· A written application must be filed with Customer Service.

· Electric and/or Water service must be in the APPLICANT’S name.

· Applicants for exemptions are allowed under one category:

Þ Senior Citizens (65 years and older)

Þ Disabled Veterans

Þ Permanently and Totally Disabled

Complete ALL information requested.  Application must be signed and dated.

PLEASE PRINT CLEARLY.

APPLICATION FOR:

(Check one only)

          Senior Citizens (65 years and older)

          Disabled Veteran

          Permanently and Totally Disabled

APPLICATION INFORMATION

(Complete all information, regardless of exemption program you are applying for).

Name: ________________________________________________

Address: ______________________________________________

Phone: ________________________  Age: ___________

Social Security Number: __________________________

Signature: _____________________________________________

ACCOUNT NUMBERS:

Electric Acct: ________________  Water Acct: ________________

PROOF REQUIRED

(Use copies—Do not enclose original documents since they will not be returned)

SENIOR CITIZEN

(Only one is required)

          Birth Certificate

          Drivers License,

          plus one other ID

          Baptismal Record

DISABLED VETERAN

        DAV Medical Card

        Other VA ID

PERMANENTLY AND TOTALLY DISABLED

      Award Letter

      from Social

      Security

      Administration

      Office

PREPARER’S INFORMATION

(Complete only if someone other than applicant prepared this form)

Preparer’s Signature: ____________________________________

Preparer’s Phone Number: ___________________________