Income Verification or Attestation

Company

This field is for validation purposes and should be left unchanged.

Which Services do you Receive From the PUD?(Required)

Check All that Apply

Electric

Water

Sewer

Broadband

Which Programs are You Applying For?(Required)

Check all that apply.

Low Income Bill Program

Low Income Rebate Program

Washer Dryer Program

Electrical Service Account Number

Please enter the electrical service account number in the dialog box, if applicable.

Water & Sewer Service Account Number

Please enter the water & sewer service account number in the dialog box, if applicable.

Name (Primary account holder)(Required)

First Middle Last

Phone (Home)(Required)

Phone (Cell)

Email(Required)

Service Address(Required)

Street Address City ZIP / Postal Code

Is the mailing address different from the service address?

Yes

Mailing Address (if different)

Street Address City State / Province / Region ZIP / Postal Code

Years/Months at current service address(Required)

I have been at this address for at least 12 months and would like more information about Budget Billing

Primary - Gross income for the last three months

DOB (mm/dd/yyyy)(Required)

Source of Income(Required)

Gross Income - First Month(Required)

Gross Income - Second Month(Required)

Gross Income - Third Month(Required)

Housing(Required)

Rent

Own

Income/Benefits(Required)

How many Total Household Members are at this address?(Required)

How many of those Household Members are 18 years or older?(Required)

Secondary (18 and older) - Gross income for the previous three months

Name (Secondary Account Holder)

First Middle Last

Phone (Cell)

DOB (mm/dd/yyyy)

Source of Income

Relationship to Primary:

Income/Benefits

Relationship to Primary:

Gross Income - First Month

Gross Income - Second Month

Gross Income - Third Month

Is there an additional household member (18 and older) at this address?

Yes

Additional Household Member (18 and older) - Gross income for the previous three months

Name

First Middle Last

Phone (Cell)

DOB (mm/dd/yyyy)

Source of Income

Relationship to Primary:

Income/Benefits

Gross Income - First Month

Gross Income - Second Month

Gross Income - Third Month

Is there an additional household member (18 and older) at this address?

Yes

Additional Household Member (18 and older) - Gross income for the previous three months

Name

First Middle Last

Phone (Cell)

DOB (mm/dd/yyyy)

Source of Income

Relationship to Primary:

Income/Benefits

Gross Income - First Month

Gross Income - Second Month

Gross Income - Third Month

Is there an additional household member (18 and older) at this address?

Yes

Additional Household Member (18 and older) - Gross income for the previous three months

Name

First Middle Last

Phone (Cell)

DOB (mm/dd/yyyy)

Source of Income

Relationship to Primary:

Income/Benefits

Gross Income - First Month

Gross Income - Second Month

Gross Income - Third Month

Is there an additional household member (18 and older) at this address?

Yes

Additional Household Member (18 and older) - Gross income for the previous three months

Name

First Middle Last

Phone (Cell)

DOB (mm/dd/yyyy)

Source of Income

Relationship to Primary:

Income/Benefits

Gross Income - First Month

Gross Income - Second Month

Gross Income - Third Month

Is there an additional household member (18 and older) at this address?

Yes

Additional Household Member (18 and older) - Gross income for the previous three months

Name

First Middle Last

Phone (Cell)

DOB (mm/dd/yyyy)

Source of Income

Relationship to Primary:

Income/Benefits

Gross Income - First Month

Gross Income - Second Month

Gross Income - Third Month

Is there an additional household member (18 and older) at this address?

Yes

Additional Household Member (18 and older) - Gross income for the previous three months

Name

First Middle Last

Phone (Cell)

DOB (mm/dd/yyyy)

Source of Income

Relationship to Primary:

Income/Benefits

Gross Income - First Month

Gross Income - Second Month

Gross Income - Third Month

Verification Document Uploads

In order for Jefferson County PUD to consider your application for Low Income Program benefits, please provide copies of the documents listed below along with a completed Low Income Program Application. Incomplete applications will not be processed. For questions, contact our Customer Service Program Specialist by calling (360) 385-8357 or via email at: dmcknight@jeffpud.org

Identification:

Photo ID for ALL household members 18 or older
Verification of ALL children living in the household (one of the following)

Photo ID (School ID, state ID, driver’s license, or passport)

File(Required)

Drop files here or

Accepted file types: pdf, jpg, jpeg, doc, docx, png, Max. file size: 128 MB.

Income Statements

Verification of Income for ALL household members of the four months prior to your appointment

Earned Income - Previous three month's paystubs
Unemployment - Printouts or Stubs
Interest Income-Bank Statements
Copy of Prior Year's Taxes (1040, 1099, including W-2s)
SSI Social Security, VA Benefits, or Pension - Determination letter or DSHS statements
TANF or ABD - Determination letter or DSHS statements
Child Support received or paid - DSHS statement or processed check copies

***Primary applicant must be a responsible party on the PUD account that will be billed at the reduced low-income rate.

File

Drop files here or

Accepted file types: pdf, jpg, jpeg, doc, docx, png, Max. file size: 128 MB.

Additional Details/Notes

Applicant Signature(Required)

Date(Required)

Co-Applicant Signature

Date

Once application has been submitted, we will reach out to you to discuss how to submit income verification.

**Primary applicant must be a responsible party on the PUD account that will be billed at the reduced low-income rate.

This claim is subject to audit: Any person willfully giving false information on this application shall be subject to the perjury laws of the State of Washington. Any exemption granted through erroneous information provided by the applicant shall: be subject to the correct fee being assessed, plus a 100 percent penalty.

Appeal on Denial of Claim: If the applicant does not meet the qualification as provided by the District guidelines, the applicant may request an appeal hearing as set forth in section 12.2 of the Jefferson County PUD No. 1 Customer Service Policy.

I certify under perjury under laws of the State of Washington that all information I have provided in order to apply for the PUD No. 1 of Jefferson County's Rate Reduction Program is true, complete and correct.

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