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2. City of Anacortes - Utility Account Number*
   Please provide your City Utility Account Number:
4. Name on City of Anacortes Utility Bill*
5. Email Address*
7. Service Address*
8. Phone Number*
   *We will only call if there are questions regarding this application*
10. Housing Status*

    1. Own Home
    2. Rent/Lease
11. Does your name appear on the bill*

    1. Yes
    2. No

    (If your name does NOT appear on the bill you will NOT be eligible for the discount)
13. Number of Members in the Household*

    (This includes dependents)

    1. Myself Only
    2. Two (2) individuals
    3. Three (3) individuals
    4. Four (4) individuals
    5. Five (5) individuals
    6. Six (6) individuals
    7. More than six (7 plus) individuals
14. Total Combined Gross Monthly Income*
    Please provide combined total gross monthly income from all individuals
16. Required Documentation - All Gross Income:*

    1. Most recent IRS Tax Return
    2. IRS Wage and Income Transcript

    All persons 18 years or older living in your home

17. Required Documentation:*

    1. State driver's license
    2. State identification card
    3. Passport or permanent resident card

    All persons 18 years or older living in your home

19. Please upload required document here:
20. Please upload required document here:
21. Please upload required document here:
23. I have included all necessary paperwork*

    1. Documents are attached
    2. Documents will be mailed

    *If mailing - this application will not be processed until all documentation is received*
25. 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.
27. I have read and agree to the above legal statement*

    1. I have read and accept the above statement
29. 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.
31. Electronic Signature
Leave This Blank:


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

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field