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2. Owner Application for Low Income Rate (Effective July 1, 2023)

   I hereby claim and attest to the following:                                                                

   1. I reside in the residence where the discounted rate(s) is being requested;    
   2. My residence has a separate water meter;
   3. My combined household gross income from all sources, excluding children under eighteen, for the previous year did not and for this year (estimated) will not, exceed the dollar amount listed below based on the size of the household: 
4. Household Size/Income

   1. 1 person/$47,950
   2. 2 person/$54,800
   3. 3 person/$61,650
   4. 4 person/$68,500
   5. 5 person/$74,000
   6. 6 person/$79,500
   7. 7 person/$84,950
   8. 8 or more persons/$90,450
5. Select One

   1. New Application
   2. Renewal
6. Please Note:

   Renewal:     Application for renewal of the Low Income Rate must be made annually during the month of June each year.  Failure to renew will result in reinstatement of regular rates.

   Discounts:   The Low Income Rate will commence on the next billing date after the application is approved.

   If you have any questions or are having difficulty completing this form, please call (425) 487-4108.

8. 4.  I agree to notify the District should I move from the residence; or if my gross annual income exceeds the amount above.

   5.  I agree to pay the District the difference between low income rate and the regular rate, should it be determined that I am not qualified for low income rates.

   6.  I agree to provide the District with financial information to support my application and verify my eligibility as required.

   7.  I acknowledge that information provided by me in support of my application is a public record and subject to public disclosure.  I agree to waive any claim of confidentiality in any information provided and I agree to release Woodinville Water District, and its employees, agents, officers and Commissioners from any liability or claims which might arise from the disclosure of such information to any other party or entity.

10. First Name
11. Last Name
13. Address
15. City
16. State
17. Zip Code
19. Customer Number (if known)
20. Phone Number
22. Email Address
24. I certify, under penalty of perjury under the laws of the State of Washington, that the information provided is true and correct.
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

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