Senior Citizen and Disabled/Low Income Persons Adjustment of Water Service Charges

Please complete the following form to apply to for an adjustment to your water service bill.

Claimant:

First Name

Last Name

Email Address

Service Address:

Street Address Only

Mailing Address:

Only include if different form Service Address above.

Street Address

City

State

Zip Code

Description of Property:

Customer must own the property. Property must be the primary residence of the Customer.

Single Family Dwelling

Mobile Home

Type of Qualification:

Please choose from amongst the following options.

I will be 61 years of age or older on or before December 31 of the year in which this adjustment is filed.

I am physically disabled and as such, retired from regular gainful employment by reason of such disability.

I am a surviving spouse of a person who was approved for this exemption and I am at least 57 years old.

Confirmation:

Any adjustment granted through erroneous information shall be subject to penalty. I swear under the penalties of perjury that all of the foregoing statements are true.

Signature of Claimant

Phone

Message:

How can we help you?

Do NOT include any sensitive data in this form, such as SSN, Credit Card or Payment information.

This claim is subject to audit by the Department of Revenue.

Customer must own the property and account must stay current.
Property must be the primary residence of the customer.
Customer must have exemption from Douglas County on property taxes.

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