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Customer Assistance Program ApplicationMetropolitan St, Louis Sewer district stny- `_' ! O Customer Assistance Program - F.A.Q. What is the Customer Assistance Program? The Board of Trustees for the Metropolitan Saint Louis Sewer District (MSD), through the adoption of Ordinance No. 13826, offers a revised Customer Assistance Program (formerly Low Income Assistance Program) effective May 8, 2014. For qualified low- income, elderly, and disabled customers who receive sewer service from MSD. The assistance program is available to single family homeowners, tenants with property owner approval and multi -unit properties up to six (6) units. Customers will receive a rate reduction equal to 50% of the current charges for wastewater services on their monthly sewer bill. Who is Eligible under this Program? • Income eligible customers. o Total annual income for the previous year is less than 200% of the most recent Health & Human Services (HHS) poverty guidelines or 250% for Disabled Individuals and seniors at least age 62. o Liquid assets and real estate must be less than $10,000, excluding house of residence and vehicles. Homeowners who are elderly or disabled individuals are not subject to the liquid asset guideline. • Own/reside or reside as a tenant in property full-time for which you want to receive the rate reduction. • Property is a single-family residence or multi -unit property (up to six units). • Service name on the account must be property owners name or name of the applicant. What supporting documents will be required? 1. Copy of current year paperwork (within 6 months of application) showing acceptance into LIHEAP (Low Income Home Energy Assistance Program). If this is provided, items 2 through 5 below are NOT REQUIRED to be included with application. 2. Proof of all income sources for all persons living in your home', if paid weekly or bi- weekly need thirty (30) days of income. If you are paid monthly, sixty (60) days of income verification is needed. 3. If you receive food stamps, proof of amount & the Food Stamp Budget Summary. 4. If you are self-employed, provide most recent U.S. Federal Tax return form & 1099. 5. Proof of the amount(s) of any liquid assets or real estate, excluding house of residence". 6. Medical Certification (if applying under Disabled) completed by Medical Physician. 7. Proof of age by copy of valid government issued identification (Driver's License, State or Military ID card). 8. Tenants must provide an original notarized affidavit (Tenant Verification Form) with property owner's signature and copy of Rental/Lease agreement stating responsibility for MSD sewer service charges. How do you apply for the program? • Customers who wish to apply for the Customer Assistance Program must complete the entire application and return it to MSD's Customer Assistance Program, (AIR) Division. • All current Customer Assistance recipients will be required to reapply and meet new qualifications once the two (2) year period is exhausted. If found ineligible, the rate reduction will stop with the next month following determination of ineligibility. • Falsifying information or failure to notify a change in eligibility status may lead to: o Recovery of past reductions o Civil and/or criminal actions o Termination of sewer service How will you receive the rate discount and how long will it be effective? • The rate discount will be applied to your account monthly, before you receive the bill. • Rate discount for qualified applicants shall begin on the first full month following approval of the application. • The rate discount will remain in effect for a period of two (2) years from the date of approval. All applicants must reapply bi-annually (every two years). How do I maintain eligibility in the Program? • Eligibility must be established annually. A renewal application will automatically be sent 60 days prior to the expiration date to all applicable customers. • New application must be postmarked no later than 30 days prior to the program expiration date indicated in the notification letter. • Should any renewal application found to be ineligible; the rate reduction will be removed the month following the date of ineligibility. • The monthly reduction is non -transferable to another person or place of residence. • Customer must remain current on all future reduced rate charges. • Non-payment may result in collection efforts and/or removal from the program. • If you are a new applicant with a prior past due balance MSD has tools that may be available to help you. Additional questions? Please contact MSD by calling Customer Service at 1-866-281-5737 or by e-mail at billingquest(a stlmsd.com. Most common income items include: Recent Paystubs, Recent year's signed tax return with W-2 and/or 1099, Social Security, Disability, Supplemental Social Security, Pensions, Interest, Wages, IRA withdrawals, Gambling winnings, Rents, Annuities, Insurance contracts, Unemployment Compensation, Gain from sale of property. Income not included: Social Security Disability until age 65, Medicare, Veterans Disability Benefits, Disability Pensions paid by employee, Disability Pensions paid by employer as excluded by IRS regulations, Workers Compensation, Welfare, Aid to Dependent Children(ADC), Life Insurance due to death, Railroad Retirement benefits in Adjusted Gross Income Types of liquid assets or real estate: Checking account, Saving/Credit Union, Certificates of Deposits(CD), Annuities, stocks/bonds/mutual funds, Money Market Funds, IRA/Keough/Deferred Compensation, all real estate other than your primary house of residence. Items that will not be accepted for proof of income; Copies of Bank Statements, Deposit Slips, Insurance Payments, License Renewal forms Revised 4/2018 LlettaluAitan St- Lopit t Oititriti MSD Account #: CUSTOMER ASSISTANCE APPLICATION APPLICANT INFORMATION: MUST COMPLETE ENTIRE FORM Applicant Name: Address Line I: Address Line 2: Clty: NEW APPLICANT Date of Birth: RENEWAL PROPERTY OWNER TENANT Apt # last four (4) digits - Social Security Number : Apt, # Daytime Telephone #: Zip Code: LIST OF ALL RESIDENTS IN HOUSEHOLD: (List additional household members on separate sheet of paper) Name to 2. 3, 4, 5, Social Security # L Relationship to Applicant Date of Birth LAST MONTH (Gross income) Salary/Wages/Tips/self-employment Income Social Security, Supplemental Security, Disability & Welfare Pension or Annuities distributions Unemployment Compensation Alimony or Child Support Rental Income (other than household) Interest & Dividends Other Sources Total Income $ CURRENT AMOUNT Checking/Savings Accounts Certificate Deposits/Money Market Annuities Stocks/Bonds/Mutual Funds IRA/KEOUGH/Def. Compensation Real Estate (other than household) Total Value All applica its MUST provide pro of ALL Income Unless current Approved Acceptance Letter from LIHEAP is deluded with Application (OVER) Check One: Required Elderly (Please include copy of Driver's License or State I l with proof of age.) Disabled (Please include medical certification of disability from Physician.) Income Eligible (Must complete Customer Assistance application as instructed.) Tenant (Please include a copy of Rental Agreement and notarized Tenant Verification Form.) How did you hear about the Low Income Program? Please circle one: A. Radio B. Newspaper Co Help Agency D. Word of Mouth E. Other (Please State) PLEASE RETAIN COPY OF APPLICATION FOR YOUR RECORDS AND RETURN COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION INCLUDING PROOF OF INCOME TO: MSD ACCOUNTS RECEIVABLE DIVISION CUSTOMER ASSISTANCE PROGRAM 2350 IV1AIt GET STREET ST, LOUIS, MO 63103 FOR ADDITIONAL INFORMATION: PHONE - 1-866-281-5737 or e-mail at billingquest(a�stlm sd.com I AUTHORIZE THE METROPOLITAN SAINT LOUIS SEWER DISTRICT (MSD) TO EXAMINE ANY FINANCIAL RECORDS THAT RELATE TO MY INCOME. I DECLARE UNDER PENALITIES OF PERJURY THAT THIS APPLICATION (INCLUDING ANY ACCOMPANYING SCHEDULES AND STATEMENTS) HAS BEEN EXAMINED BY ME AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IS A TRUE, CORRECT AND IS A COMPLETE RETURN AND REPORT. *Signature of Applicant (*Required) Date (*Require OFFICE USE ONLY Date Received: Revised 6/2015 rim NISEI Metropolitan St. Louis Sewer District Customer Assistance Program Medical Certification Section 1: To be completed by Physician I certify that is under my care and by Print Name of Patient my diagnosis is completely and permanently disabled. Print Physician's Name Name of Practice Type of Practice Telephone Number Address Signature of Physician Section 2: MUST be completed by MSD Customer I understand that this document is only for verification purposes in the determination of my eligibility for MSD's Customer Assistance Program (CAP). I certify that this document has been completed by a recognized healthcare provider as indicated above. I understand that falsification of this document can lead to removal from the program. Print Customer's Name Signature of Customer Service Address Telephone Number Return with completed Customer Assistance Application to: MSD Customer Assistance Program 2350 Market Street St. Louis, MO 63103 Revised 5/2015 Metropolitan Si Louis 3twaer District Customer Assistance Program Tenant Verification Form (if you are the Homeowner & reside in property...Do not complete) Property Owner and Tenant i certify that resides as a tenant in my Print Tenant's name Property located at MSD account # Tenant's Signature Name Property Address Telephone Number Name of Property Owner Property Owner Address Signature of Property Owner Property Owner and Notary I understand that this document is only for verification purposes in the determination of eligibility for MSD's Customer Assistance Program (CAP). I certify that this document has been completed by me and notarized as indicated. I understand that falsification of this document can lead to removal from the program. Property Owner State of Missouri Signature of Property Owner County (and/or City) of Subscribed and sworn before me this day of , 20 (by Notary Signature (Seal) Return with completed Customer Assistance Application to: MSD Customer Assistance Program 2350 Market Street St. Louis, MO 63103 Revised 5/2015 Mars Eligibility Guidelines for Customer Assistance Program *2D18 U.S. Poverty Guidelines effective January 17, 2018 Persons in family 1 2 3 4 5 6 7 8 For each additional person, add `Annual Income $12,140 $16,460 $20,780 $25,100 $29,420 $33, © $38,060 $42,38 J $4,320 Annual] Mco fl e $24,280 ti$32,920 $60,200 $53,340 $87,480 $78,120 $84,780 $8,640 f (/ 200% Age 62 and older/Disabled Annual Income @ 250% $30,350 $4`,ti1 60 $6` ,960 $62,750 $73,660 $84,350 $96,150 $105,960 revised 112017