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2. Ensure You Meet The Following Assistance Program Conditions Prior To Completing The Application
4. You are a City of Westminster water customer. Your name is on the account and you currently occupy the household. (Additional documentation may be provided if you name is not listed on the account.).*

   1. Yes
   2. No
6. Does your water account have any leaks?*

   1. Yes
   2. No
8. Your account is 35 days or more past due, you have a late/disconnect notice, or you are currently disconnected*

   1. Yes
   2. No
10. You have never received the Hardship credit before.*

    1. Yes
    2. No
12. Name of Applicant (as it appears on account)
14. First Name*
15. Last Name*
17. Water Bill Account Number*
19. Do you pay the water bill?*

    1. Yes
    2. No
21. Address of Applicant
23. Street Address*
25. Street Address Line 2
27. City*
28. State*
30. Postal / Zip Code*
32. Phone Number*

    Please enter a valid phone number.

34. Email*

    example@example.com

36. Do you own or rent your home?*

    1. Own
    2. Rent
38. Preferred method of contact*

    1. Phone
    2. Email
40. Number of persons in household*
42. Number of persons in household 18+ years old*
44. Number of persons in household currently employed*
46. Provide a brief summary of the Hardship your household is currently experiencing*
48. Submit the Following Verification Documents With Your Completed Application

    *All documents must be submitted with application, missing documents will delay processing time.

    • Documentation supporting the Hardship you are experiencing (ie: letter from employer or doctor, proof of reduced hours/job separation, etc)
    • Copy of most recent mortgage statement or current lease
    • 2 most recent bank statements
    • All recent income documents for all persons age 18 or older residing in the household.  

      (Income = wages, social security, retirement/pension/stock distributions, unemployment, child support, alimony, rental income, tips, grants and monetary gifts/inheritance, etc.

50. Upload required verification documents here (Multiple documents can be uploaded)*
54. Electronic Signature*

    1. Agree

    I agree that the information I have provided in this application is truthful and accurate and that checking this box and entering my information below constitutes a legal and enforceable signature for this application in accordance with the provisions of the provisions of the Colorado Electronic Signatures Act 24-71-101.

56. Full Name (including middle initial, if applicable)*
58. Street Address*
60. Street Address Line 2
62. City*
63. State*
65. Postal / Zip Code*
67. Valid Email*
Leave This Blank:


69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

* indicates a required field