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Customer Assistance Program Application - Complete PacketM What is T th (f in as ow ra m Who is E     What su 1. C in it 2. P w in in 3. If fo 4. P 5. M 6. P M 7. T pr M METROPOLITA the Custom The Board of he adoption o formerly Low ncome, elder ssistance pro wner approv ate reductio monthly sewe Eligible und Income elig o Total Health Indivi o Liquid reside not su Own/reside the rate redu Property is Service nam upporting do Copy of curre nto LIHEAP tems 2 throu roof of all in weekly need t ncome verifi ncome). f you are self orm & 1099. roof of the a Medical Certi roof of age b Military ID c Tenants must roperty own MSD sewer s N ST. LOUIS SE (314) mer Assistan f Trustees for of Ordinance w Income A rly, and disab ogram is ava val and multi on equal to 5 er bill. der this Prog gible custome annual incom h & Human iduals and se d assets and ence and veh ubject to the e or reside a uction. a single-fam me on the ac ocuments w ent year pape P (Low Inco gh 5 below a ncome sourc thirty (30) d ication is nee f-employed . amount(s) of ification (if a by copy of v ard) if 62 ye t provide an ner’s signatur service charg EWER DISTRICT 768-6260 | WW Custo nce Program r the Metrop e No. 13826 Assistance Pr bled custom ailable to sin i-unit proper 50% of the gram? ers. me for the p Services (H eniors at leas real estate m hicles. Home liquid asset as a tenant i mily residenc ccount must will be requir erwork (with ome Home E are NOT RE ces for all pe days of incom eded (BANK , provide mo f any liquid a applying und valid governm ears and olde original not re and copy ges. T | 2350 MARKE WW.MSDPROJE omer Assis m? politan Saint 6, offers a rev ogram) effec mers who rece ngle family h rties up to si current cha revious year HS) poverty st age 62. must be less eowners who guideline. in property ce or multi-u be property red? hin 6 months Energy Assi EQUIRED to rsons living me. If you ar K STATEME ost recent sig assets or real der Disabled ment issued er. tarized affid of Rental/Le ET STREET | S ECTCLEAR.ORG stance Pro t Louis Sewe vised Custom ctive May 8 eive sewer s homeowners ix (6) units. C arges for wa r is less than y guidelines than $10,00 o are elderly full-time fo unit property owners nam s of applicat istance Prog o be included in your hom re paid mont ENTS NOT gned copy o l estate, excl d) completed identificatio davit (Tenant ease agreem ST. LOUIS, MO 6 G ogram - F. er District (M mer Assistan , 2014. For service from , tenants wit Customers w astewater ser n 200% of th or 250% for 0, excluding or disabled or which you y (up to six u me or name o tion) showin gram). If t d with applic mei, if paid w thly, sixty (6 ACCEPTED of U.S. Feder luding house d by Medica on (Driver’s t Verificatio ment stating r 63103-2555 .A.Q. MSD), throu nce Program qualified low MSD. The th property will receive a rvices on the he most recen r Disabled g house of individuals u want to rec units). of the applica ng acceptanc this is provid cation. weekly or bi- 60) days of D for proof o ral Tax retur e of residenc al Physician. License, Sta n Form) wit responsibility ugh m w- a eir nt are ceive ant. ce ded, - of rn ceii. ate or th y for 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, (A/R) 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 bi-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@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 1/2020 APPLIC MUST C LIST O need pro All ap Appro _________ Signa I AUTHOR DECLARE EXAMINE Applicant Address L Address L City: 1. 2. 3. 4. 5. Monthl In Soci Disability P Rental P CANT INFOR COMPLETE F ALL RESID oof of Income pplicants M oved Accep ________________ ature of App RIZE THE METRO E UNDER PENAL ED BY ME AND T t Name: Line 1: Line 2: N ly Salary/Wages ncome-Include c ial Security, Sup y & Welfare Incl Pension or Annui Unemployment Alimony or C Property Income Interest & Other S Total I RMATION: ENTIRE FOR DENTS IN HO e, Student ID o MUST pro ptance Le _______________ plicant (Req OPOLITAN SAIN LITIES OF PERJU TO THE BEST OF Name /Tips/self-emplo current paystub pplemental Secur lude Approval S ities distribution t Compensation Child Support e (other than hou Dividends Sources Income RM OUSEHOLD: or equivalent) ovide proo etter from __________ quired) NT LOUIS SEWER URY THAT THIS F MY KNOWLED Apt # Apt. # L oyment bs $ rity, Statement ns usehold) $ (List addition of of ALL LIHEAP R DISTRICT (MS APPLICATION ( DGE AND BELIE Da La Da Zip Last four (4) d LAST MONTH (Gross Income) CUSTOM NEW PRO nal household Income an is include SD) TO EXAMIN (INCLUDING AN EF IS A TRUE, CO ate of Birth: ast four (4) digits aytime Telephone p Code: digits SS # C Certi S IRA/ Rea MER ASSI W APPLICAN OPERTY OW d members on nd Proof o ed with Ap ____ Da NE ANY FINANCI NY ACCOMPANY ORRECT AND IS - Social Security N #: Relationsh Checking/Saving tificate Deposits/ Annuiti Stocks/Bonds/M /KEOUGH/Def. al Estate (other th Total Va ISTANCE M NT _____ WNER _____ separate pape of Age (ID pplication. _______________ ate (Requir IAL RECORDS T YING SCHEDULE A COMPLETE R Number : hip to Applica gs Accounts /Money Market ies Mutual Funds f. Compensation han household) alue E APPLIC MSD Accou RENEWAL TENANT er/Members 1 D) unless C . _____ ed) THAT RELATE T ES AND STATEM RETURN AND RE ant Date CURRENT A $ $ ATION unt #:______ L _______ _______ 19 and older Current O MY INCOME. MENT(S) HAS BE EPORT. of Birth AMOUNT __________ I EEN ___ Check One: Required Elderly ______ (Please include copy of Driver’s License or State ID 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 C. 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 MARKET STREET ST. LOUIS, MO 63103 FOR ADDITIONAL INFORMATION: PHONE – 1-866-281-5737 or e-mail at billingquest@stlmsd.com Revised 01/2020 OFFICE USE ONLY Date Received: ____________ Revised 5/ Section 1:     I certify my diag      Print Physic    Type of Prac    Telephone N   Section 2:   I underst eligibility complete falsificati    Print Custom      Service Add /2015  To be compl y that ____ gnosis is co   ian’s Name    ctice      Number   MUST  be co tand that thi y for MSD’s C ed by a reco ion of this do   mer’s Name    ress    Return with c METRO CU   C leted by Phys __________ Print   ompletely a                   ompleted by M s document Customer As gnized healt ocument can             completed Cu OPOLITAN ST USTOMER AS 2350 MA ST. LOUIS ustomer A Medica sician  _________  Name of Patien and perma MSD Custome t is only for v ssistance Pro thcare provi n lead to rem ustomer Assis T. LOUIS SEW SSISTANCE ARKET STRE S, MO 63103     Assistance P al Certifica _________ nt  anently dis    Name     Addre    Signa er  verification p ogram (CAP) der as indica moval from t    Signa    Telep stance Applic WER DISTRI PROGRAM EET 3-2555  Program  tion  _______ is abled.    e of Practice    ess    ture of Physicia purposes in  ).  I certify th ated above.  the program   ture of Custome   phone Number cation to:  ICT  s under my       n  the determi hat this docu  I understan m.    er    y care and        ination of m ument has b nd that      by         y  een      Revised 5/ Section 1:  I certify t Property Tenant’s Sig Property Ad Property Ow Section 2:  I understa MSD’s Cu notarized program.  Property Ow State of Mis County (and Subscribed  Notary Sign /2015  (If you ar to be comple that ______ y located at _ gnature Name  ddress  wner‐Telephone to be comple and that this d stomer Assist  as indicated. wner  ssouri  d/or City) of ___ and sworn befo ature ________ Return with c METRO CU C re the Prope eted by Prope ___________ Print Ten __________ e Number  eted by Prope document is  tance Program .  I understan ______________ re me this _____ ______________ completed Cu OPOLITAN ST USTOMER AS 2350 MA ST. LOUIS ustomer A Tenant V erty Owner & erty Owner an ___________ nant’s name  ___________ erty Owner an only for verif m (CAP).  I ce d that falsific _______ _  __day of ______ ____________    ustomer Assis T. LOUIS SEW SSISTANCE ARKET STRE S, MO 63103 Assistance P erification & Reside in  nd Tenant ____ resides _____ MSD a Name Prope Signa nd Notary  ication purpo rtify that this cation of this d   Signa _____, 20___ (by (Seal)  stance Applic WER DISTRI PROGRAM EET 3-2555  Program  n Form  property…D s as a tenan account #__ e of Property Ow erty Owner Add ature of Property oses in the de s document h document ca ature of Propert y ____________ cation to:  ICT  Do not comp nt in my   _________  wner  dress   y Owner  etermination  has been com an lead to rem ty Owner  ______________ plete)  of eligibility f pleted by me moval from th ___________)  for  e and  he  MSD's Eligibility Guidelines for Customer ; sa Ea-1]@9 Program 2(32.8 U.S. Poverty Guidelines Glitolive January 17, ME Persons In family 1 -2 Age 62 and older/Disabled Annual Income Annual Income .200% Annual Income 0 250% $12,700 $25,52O $17,240 $3080 $31,900 $43,100 3 6 7 $21,720 $26,200 $30,680 $43,440 $54,300 $52 400 $61 60 $35,160 $70,320 $39,640 $19,280 $65,500 $76,700 $87,900 $99,100 $44,120 $66,240 $110,300 For each addiiiorson, add $4,480 $8,960 $11,200 PaV1111111 mama