Snoqualmie, WA

Eligibility Requirements

Ordinance no. 1133 of the City of Snoqualmie creates a low-income residential customer class. A reduced utility rate for this customer class is established provided all criteria defined in this ordinance are met. The family income guidelines are those effective for 2020 and are subject to yearly changes as determined by the U.S. Department of Housing and Urban Development.
City Ordinance No. 1133
Eligibility Requirements
Before filling out the following application, check below to ensure you meet the eligibility requirements. Household size is the number of ALL people (adults and children) living at the service address. The income limits are to include the combined income from ALL sources of ALL ADULT members (age 18 or older) of the household, as indicated on the Adjusted Gross Income line of your tax return.
Household Size and Combined Income
1. 1 - $41,800 or less
2. 2 - $47,800 or less
3. 3 - $53,750 or less
4. 4 - $59,700 or less
1. 5 - $64,500 or less
2. 6 - $69,300or less
3. 7 - $74,050 or less
4. 8 - $78,850 or less
For questions, email Tami Wood: twood@snoqualmiewa.gov
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Account and Contact Information

First Name*
Last Name*
Service Address*
City*
State*
Zip Code*
Phone Number*
Email Address
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Declaration of Eligibility

1. I own or rent (choose below) and reside in the residence where the discounted rates are being requested. *
1. Own
2. Rent
2. My residence has a separate water meter.*
3. I am not, nor is any other adult member (over age 18) of the household, claimed as a dependent on another federal income tax return.*
1. I certify that the above statement is true.
4. If I am not the named customer on the City's utility bill, I have provided documentation that I am the named tenant in a lease or rental agreement for this residence. *
Date documentation was provided:
Date documentation was provided:
5. My water consumption in the past 12 months is less than 100 ccf. If you are unsure, you may email Tami at twood@snoqualmiewa.gov or call 425.888.1555. *
If the answer is yes, skip to # 6. If the answer is no, please fill out sections 5a, 5b and 5c.
1. Yes
2. No
5a. Written justification was provided to the Finance Director on:
5a. Written justification was provided to the Finance Director on:
5b. Finance Director's decision was:
1. Approved
2. Denied
5c. Decision was approved or denied on the following date:
5c. Decision was approved or denied on the following date:
6. My household size is:*
Please provide the number of people (all ages) living in your household.
7. My household includes the following members:*
Please provide the names of all family members living in your household.
8. Select the number of people living in your home (household size from #6) that also corresponds to the combined income from all sources of all adult members in the home (18 years and older). Check only one.*
These are the income limits for 2020. The annual income of all adults in your home must be at or below the limit for the number of people living in your home.
9. Have you applied for or are you currently receiving unemployment benefits?*
If yes, please provide proof of your most recent unemployment payment.
10. I understand that I will be required to establish continuing eligibility for the low-income utility rate by providing a new declaration each year*
11. I understand that knowingly providing false information on this declaration constitutes perjury in the second degree, the penalty for which is confinement in a state correctional institution for five years, or by a fine in an amount fixed by the court of ten thousand dollars, or by both such confinement and fine.*
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Supporting Documents

Please attach a copy of your most recent Federal Tax Return
PLEASE BE SURE TO WHITE OUT ANY SOCIAL SECURITY NUMBERS BEFORE SCANNING AND UPLOADING.
Use this field to upload additional documents, if necessary
Use this field to upload additional documents, if necessary
Document Submission
If you cannot upload your tax return with this form, you must scan or take a photo and email it to Tami Wood. Email: TWood@snoqualmiewa.gov. If you do not have email, please call Tami at 425.766.3700. PLEASE BE SURE TO WHITE OUT ANY SOCIAL SECURITY NUMBERS BEFORE SCANNING AND UPLOADING.
Please select one:*
1. I have uploaded my supporting document(s)
2. I will email my supporting documents.
3. I do not have email and will call Tami at 425.766.3700 to discuss options
PLEASE BE SURE TO WHITE OUT ANY SOCIAL SECURITY NUMBERS BEFORE SCANNING AND UPLOADING.
I understand that the combined Adjusted Gross Income of all adults living in the household, as indicated on all household members' tax returns must match what I have selected for # 8 for my household income. *
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Signature Page

By typing my name below, I certify that all of the information contained herein is true and accurate to the best of my knowledge.*
Today's Date*
Today's Date
Email Address
Please provide an email address for questions about your application

Leave This Blank:

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

This field is not part of the form submission.
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