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2. Instructions
   Please review the definitions and instructions, found here.
4. Name:*
5. Utility Account #:*
7. Service Address: *
9. City*
10. State*
11. Zip Code*
13. Telephone Number:*
15. Verification*

    1. I own/rent my place of residence and it is situated within the City limits of the City of Sultan and the above referenced utility account is in my name.
17. My combined annual household income is:*

    Please Check One

    1. 1 person household – less than $18,576 yearly or $1,548 monthly
    2. 2 person household – less than $25,032 yearly or $2,086 monthly
    3. 3 person household – less than $31,500 yearly or $2,625 monthly
    4. 4 person household – less than $37,968 yearly or $3,164 monthly
19. Financial Documents*
    Upload verification of income documents here
21. This income figure includes all earned income as well as retirement income, social security benefits, disability benefits, investment income, interest income, capital gains, and net rental income from all real estate. A credit against annual household income for property taxes (with proof) shall be used in calculating whether an applicant is qualified for the discount or not. My income does not exceed the above-indicated amount. I hereby make application for a utility rate reduction.
23. I agree*

    1. I agree
24. Financial Declaration
    By Checking the box to the left you certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing information regarding income verification submitted is true and correct.
26. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
28. Electronic Signature*
29. Date*
    Date
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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

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