Fillable CITY OF BREMERTON DISCOUNT APPLICATION (City of Bremerton)

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CITY OF BREMERTON DISCOUNT APPLICATION (City of Bremerton)

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The CITY OF BREMERTON DISCOUNT APPLICATION (City of Bremerton) form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for City of Bremerton

BROWSE CITY OF BREMERTON (WA) FORMS

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Full Name
(enter below)
Date of Birth
MM/DD/YY
Income Type Gross Earned &
Unearned Income
$
$
$
$
$
Total Income:
$
CITY OF BREMERTON DISCOUNT APPLICATION
***INCOMPLETE APPLICATIONS OR MISSING DOCUMENTATION WILL DELAY PROCESSING***
UTILITY BILLING • 345 6TH ST., STE. 100 • BREMERTON, WA 98337-1891 • PH: 360-473-5316 • FX: 360-473-2330 • billing@ci.bremerton.wa.us
HOUSEHOLD OCCUPANTS/MEMBERS
List all household occupants. An occupant is anyone who lives in the home, whether a relative or not. Even if the person
does not pay rent, you must list him/her as an occupant and include below. If applicable, list the names the same as
they appear on SSA/SSI paperwork.
INCOME TYPES AND DOCUMENTS REQUIRED
SERVICE ADDRESS
MAILING ADDRESS (include City and Zip Code)
If you do not have proof of income or you did not work, you must submit one of the following documents:
• Proof of lack of income. Visit the IRS website: and complete the “Verication of Non-ling” for 2020 and submit to the IRS. When you receive the
report from the IRS attach a copy to the application.
• A letter explaining your circumstances. We may request more information or supporting documentation.
• Wages, Tips & Salaries – four (4) pay stubs
• Self-Employment Income – previous year’s tax return
• Social Security & Other Retirement Benets – SSA award letter &/or
previous year tax return (over 62)
• SSI or Disability Payments – SSI award letter or bank statement
• Child or Spousal Support – court documents
• Rental Income or Partnerships – need a letter of self certicate
• Withdrawals or Dividends – previous year tax form
• Unemployment Benets – unemployment award letter
• Workers Compensation (L&I) – a pay stub
• Annuities – W-2
• Copy of Photo ID
REV 12/2020
PHONE NUMBER
Home Mobile
OWNER RENTER
New
Renewal
RETURN BY:
EMAIL ADDRESS
FOR CITY OF BREMERTON USE ONLY
ACCOUNT #
SR / DIS / LIQ / NQ
ACCOUNT HOLDER’S NAME
(SEE OTHER SIDE)
BREMERTON CITY LIMITS DISCOUNT
Qualifying service locations within Bremerton city limits will receive a discount with Waste Management.
Applying for Bremerton city limits cable discount?
YES
NO
By signing this agreement I certify that the information on this form is true and correct and that false or incorrect information will result in denial or immediate removal of
discount(s). I also agree to the following: I will notify Utility Billing of signicant changes to income and/or number of occupants. Audits of discounts may occur at any time.
SIGNATURE OF ACCOUNT HOLDER
X
DATE
Comcast Only
PROGRAM REQUIREMENTS
is program is designed to give relief to low-income senior/disabled citizens. Utility account must be in the name of
the applicant. Applicant must reside at the service address.
SENIOR DISCOUNT
• Age 62 or older
• Total household annual income $40,000
DISABILITY DISCOUNT
• Legal blindness, or a disability qualifying for handicapped parking privileges, or a disabled, handicapped
or incapacitated person as dened under any other existing state or federal program.
• Total income, including that of your spouse, co-tenant or anyone else living in house, does not exceed
the listed income levels per size of household:
MAIL: City of Bremerton Utility Billing
345 6th Street, Suite 100
Bremerton, WA 98337-1891
EMAIL: billing@ci.bremerton.wa.us
Household Members Monthly Income Annual Income
1 $1,518 $18,216
2 $2,058 $24,696
3 $2,598 $31,176
4 $3,138 $37,656
5 $3,678 $44,136
6 $4,218 $50,616
7 $4,758 $57,096
8 $5,298 $63,576
W
ith the approval of your application, a discount of 40 percent will be applied to each rate.
Residents within Bremerton city limits will receive a discount with Waste Management.
City residents may also qualify for a Comcast basic cable discount. Check the appropriate box on the
application form if you would like your application forwarded to Comcast for consideration.
Please return this completed and signed application, along with required documentation to:
CITY OF BREMERTON
LOW-INCOME SENIOR/DISABLED SUBSIDY PROGRAM
UTILITY BILLING • 345 6TH ST., STE. 100 • BREMERTON, WA 98337-1891 • PH: 360-473-5316 • FX: 360-473-2330 • billing@ci.bremerton.wa.us
QUESTIONS: visit www.BremertonWA.gov/UtilityBilling, email billing@ci.bremerton.wa.us,
or call 360-473-5316, Monday through Friday, 8:00AM to 4:30PM.
REV 12/2020
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CITY OF BREMERTON DISCOUNT APPLICATION (City of Bremerton)

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Completed 17 January 2021

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