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C:\Documents and Settings\DBuell\Desktop\SR_DISABLED_DISCFORM.doc APPLICATION FOR SPECIAL RATES FOR LOW INCOME SENIOR AND DISABLED CITIZENS DATE YOUR BIRTHDATE_____________ SPOUSE’S BIRTHDATE____________ COMBINED ANNUAL INCOME OF ALL PERSONS LIVING AT THIS ADDRESS: WAGES, SALARY, ETC. $ SOCIAL SECURITY $ INTEREST/DIVIDENDS $ RENTS/ROYALTIES, ETC. $ ALL OTHER INCOME $ TOTAL ANNUAL INCOME $ APPLICANT’S NAME SPOUSE’S NAME ADDRESS PHONE NUMBER NO. OF PERSONS IN HOUSEHOLD CITY OF MARYSVILLE ACCOUNT # I HEREBY ATTEST THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE SIGNATURE Senior applications MUST be accompanied by proof of age and income or application will be returned. Disabled applications (under age 62) MUST be accompanied by proof of disability and income or application will be returned. SEE REVERSE FOR OTHER REQUIREMENTS PLEASE RETURN APPLICATION TO: MARYSVILLE CITY HALL 1049 STATE AVENUE, MARYSVILLE, WA 98270-4234 QUESTIONS: CALL [PHONE REDACTED] ---PAGE BREAK--- C:\Documents and Settings\DBuell\Desktop\SR_DISABLED_DISCFORM_REVERSESIDE.doc Claim procedure 1. Claims for low-income senior citizens/disabled discounts shall be reflected on the utility bill following application and eligibility for directly billed customers. 2. Indirectly billed customers eligible for the low-income senior citizen/disabled discount shall be filed between January 3nd and February 28th of the year following the period for which the discount is claimed. Eligibility The dwelling unit: a. Must be occupied by the person claiming the discount; b. Claimant must be head of the household; c. Utility account must be kept current; and d. No person may claim a discount for more than one dwelling unit during the same period. The claimant must qualify in one of the following two categories throughout the period for which the discount is claimed: 1. Low-income senior citizen. a. At least 62 years of age; and b. Total household income of twenty-five thousand dollars or less. OR 2. Low-income disabled: Household income is at or below one hundred twenty-five percent of the federally established poverty level* and claimant: a. Qualifies for special parking as defined by RCW 46.16.381; or b. Is blind as defined by RCW 74.18.020; or c. Is disabled, handicapped or incapacitated as defined by any other existing state or federal program. *2010 Federal Poverty Level (125% HHS Guidelines): Household size: One $13,538 Five $32,238 Two $18,213 Six $36,913 Three $22,888 Seven $41,588 Four $27,563 Eight $46,263 ($4,675 for each additional person) Income Defined by RCW 84.36.383 Adjusted gross income as defined in the federal internal revenue code, as amended prior to January 1, 1989, plus all of the following items to the extent they are not included in or have been deducted from adjusted gross income: a. Capital gains; b. Amounts deducted for loss; c. Amounts deducted for depreciation; d. Pension and annuity receipts; e. Military pay and benefits other than attendant-care and medical-aid payments; f. Veterans benefits other than attendant-care and medical-aid payments; g. Federal social security act and railroad retirement benefits; h. Dividend receipts; and i. Interest received on state and municipal bonds