United Way of Eddy County Water Assistance Application.

First Name *

Last Name *

Address (PO Box and Street) *

City *

State *

Zip Code *

Phone Number *

Email Address *

Date Of Birth *

Total Monthly Income: *

Household Size *

Income Source #1 *

Income Source #2

Specify who your water utility company is. *

IDENTIFICATION: Upload identification for everyone in your home. Including children and all adults. (Social Security Cards are not accepted. For children, you may use school ID card or medical card.) *

INCOME: Upload all sources of income for everyone in the home. *

BILL: Upload a copy of the water bill you need assistance for. Must be the most current bill.

Li-Heap: Upload a copy of your Li-Heap letter. You do not need to be approved, but you do need to have the letter dated after October 1, 2020. If you are over the age of 65, you do not need to apply for Li-Heap.

I understand that the information I provide will be used only to determine financial need, and will be kept confidential. I further understand that the information which I submit concerning my annual family income and family size is subject to verification, and if the information I have given is determined to be false, it may result in denial of the assistance for which I have applied. My signature authorizes United Way of Eddy County to verify all information provided on this form. I certify that the above information is true and accurate to the best of my knowledge. *

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