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2. Application for Special Utility Rates and Services

   This form is used to evaluate requests for special utility service rates for low income households.  Low income utility customers may apply to receive water and sewer services at a discounted rate.

   Water/Sewer Rate for Qualified Customers Water and sewer utility rates will apply to those qualified customers who live in the City of Snohomish (98290 Zip Code) and utilize a 5/8-inch single family residential service. Customers requiring service in excess of a 5/8-inch single family residential service shall not qualify for a rate reduction regardless of income.

4. APPLY FOR A REDUCED UTILITY RATE

   If you meet the criteria above, you may apply for a reduction in your water and sewer rates. Fill out the application on the reverse of this form and submit proof of income and identification. 

   Verification of all household income (gross). Include full 2024 income tax returns OR a signed tax waiver with related schedules, current social security benefit statement, and any other related income documents for all persons 18 and older in the household. Please only provide copies of the requested information as these will not be returned.

6. Complete this form and submit with supporting documents.
8. First Name*
9. Last Name*
11. Phone Number*
12. Date*
    Date
14. Please use the following definitions in determining eligibility:

    A household in which the total annual income is below 60% Area Median Income for the Seattle/Everett area as established and amended by survey from time to time by the United States Department of Housing and Urban Development.  The current maximum levels are set at the amounts listed below.

    City utility customers apply to receive water and sewer services at a discount.  Households at 50% AMI or less will qualify for 25% of the monthly minimum charge.  Households over 50% AMI but less than 60% AMI will qualify for 50% of the monthly minimum charge.  The following definition shall be used in determining eligibility.

     

    2024 Income Limits by Household Size/Target Population Area Median Income (AMI)
    	1 person	2 person	3 person	4 person	5 person	6 person	7 person
    50% AMI	52,700	60,250	67,800	75,350	81,400	87,450	93,400
    60% AMI	63,240	72,300	81,360	90,420	97,680	104,940	112,080

16. Email Address:*
18. Full Service Address *
20. Account Number
22. How many persons live in your household?*
    -- Select One --12345678
24. What was the gross household income last year?*
26. List sources of income:*
28. Have there been major changes in household income during the current year? If yes, please explain:
30. Are you exempt from filing federal income taxes?*

    1. Yes
    2. No
32. Required Supporting Documents
    • Verification of income of household (Include full previous year income tax returns with related schedules).  If you do not filed taxes, please provide social security statement and/or other proof of income.
    • Government Identification
34. Upload Supporting Documents

    Please upload copies of your proof of income or provide copies in person or via mail at Snohomish City Hall, 116 Union Ave, Snohomish, WA 98290

36. By submitting this form I hereby swear and affirm under the penalty of perjury that the information on this application is true and correct to the best of my knowledge and belief.
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

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