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Eligibility Requirements Proof of Eligibility Utility Account No. Phone Number: DSHS Client ID No. Birth Date: Signature of Applicant: Ambulance Utility Fee Customer must be: a citizen of the City of Kennewick residing within the City limits; and 1. Customer must be: Medicaid eligible; and 2. Customer must be: receiving in-home services during the entire period of this exemption; and 3. Customer must: inform the City in writing if they no longer are Medicaid eligible or stop receiving in-home services. 4. The following Documents are required when submitting your completed application: Proof of Medicaid: Current Washington State Medicaid card; and 1. Proof of In-home Services: DSHS award letter authorizing in-home services; and 2. Proof of In-home Services: Agency / Business providing in-home 3. Medicaid Exemption Application Applicant Name: Street Address: (Utility account must be in the name of the applicant or spouse) I hereby certify under penalty of perjury that I meet all of the above eligibility requirements. by signing this application, I give authorization for the City of Kennewick to verify my eligibility for Medicaid and in-home services with Washington State Department of Social and Health Services. Date: City use only: Reviewed By: Date: Entered By: