Loading...
Customer Assistance Program Application - Complete Packet 2021 UpdatedM 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 Assistance Program *2021 U.S. Poverty Guidelines effective January 31, 2021 Persons in family *Annual Income Annual Income @ 200% Age 62 and older/Disabled Annual Income @ 250% 1 $12,880 $25,760 $32,200 2 $17,420 $34,840 $43,550 3 $21,960 $43,920 $54,900 4 $26,500 $53,000 $66,250 5 $31,040 $62,080 $77,600 6 $35,580 $71,160 $88,950 7 $40,120 $80,240 $100,300 8 $44,660 $89,320 $111,650 For each additional person, add $4,540 $9,080 $11,350 revised 02/01/2020