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2. Household Income Guidelines (total income of all persons 18+ years old in the household)

   Household Size	Monthly Income Guidelines	Yearly Income Guidelines
   1	$ 4,565	$ 54,780
   2	$ 5,220	$ 62,640
   3	$ 5,870	$ 70,440
   4	$ 6,520	$ 78,240
   5	$ 7,045	$ 84,540
   6	$ 7,565	$ 90,780
   7	$ 8,085	$ 97,020
   8	$ 8,610	$ 103,020

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

4. Ensure Your Meet The Following Assistance Program Conditions Prior To Completing The Application
6. You are a City of Westminster water customer. Your name is on the account, and you currently occupy the household. (Documentation can be provided to confirm eligibility if not on account.)*

   1. Yes
   2. No
8. Household monthly/yearly income is 60% of area median or less (See Household Income Guidelines chart)*

   1. Yes
   2. No
10. Does your water account currently have any leaks, late/disconnect notices, or is it currently disconnected? (If any of these circumstances exist, please contact 303-658-2392 once your submit your application).*

    1. Yes
    2. No
12. You have not received credit from the Bill Credit program in the past 12 months, or you are submitting a renewal application.*

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

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

    Please enter a valid phone number.

36. Email*

    example@example.com

38. Do you own or rent your home?*

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

    1. Phone
    2. Email
42. Number of persons in household*
44. Number of persons in household 18+ years old*
46. Number of persons in household currently employed*
48. Submit the Following Income Verification Documents With Your Completed Application

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

    • Current LEAP benefit letter OR
    • Previous year's tax return + 2 recent monthly bank statements OR
    • All recent income documents for all persons age 18 or older residing in the household. (Income = wages (2 most recent paystubs), social security, retirement/pension/stock distributions, unemployment, child support, alimony, SNAP, TANF, rental income, tips, grants and monetary gifts/inheritance, etc.)
50. Upload income verification documents here (Please upload all relevant documents)*
52. *3 Late Payments And/Or A Disconnection of Services Within The 12 Month Period Will Result In Termination Of The Bill Credit.
56. 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.

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


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit

* indicates a required field