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Utility Discount Program - 2021

  1. Please provide your City Utility Account Number:
  2. *We will only call if there are questions regarding this application*
  3. Housing Status*
  4. Does your name appear on the bill*
    (If your name does NOT appear on the bill you will NOT be eligible for the discount)
  5. Number of Members in the Household*
    (This includes dependents)
  6. Please provide combined total gross monthly income from all individuals
  7. Required Documentation - All Gross Income:*
    All persons 18 years or older living in your home
  8. Required Documentation:*
    All persons 18 years or older living in your home
  9. I have included all necessary paperwork*
    *If mailing - this application will not be processed until all documentation is received*
  10. Legalities - Must Read Thoroughly
    This application and supporting documentation are used to review eligibility for additional City benefits and will NOT be shared with U.S. Citizenship and Immigration Services (USCIS). I authorize the City to use these materials to enroll me in assistance programs for which I am eligible. I am aware that my information is subject to review and verification and that other documentation may be required. I grant permission to request or release information to, or from, other government agencies, or their delegated agents; this may result in receipt or denial of City benefits. Submitting this application does not guarantee eligibility or enrollment in any programs. I certify that the information I provided is accurate and complete and that I may be subject to criminal prosecution if I have knowingly given false or misleading information. I understand that if I receive assistance and have not truly disclosed all information I will be terminated from the program(s) and the City may recover the actual cost(s) for the periods I was not eligible. I will notify the City of Anacortes if my income or living situation changes.
  11. I have read and agree to the above legal statement*
  12. 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.
  13. Leave This Blank:

  14. This field is not part of the form submission.