HomeMy Public PortalAbout430792Metropolitan
St. Louis
Sewer District
APPLICANT INFORMATION:
MSD Account #:
LOW INCOME APPLICATION
NEW APPLICANT
RENEWAL
Applicant Nante:
Date of Birth:
Address Line 1:
Apt #
Social Security Number:
Address Line 2:
Apt. #
Daytime Telephone #:
City:
Zip Code:
OF ALL RESIDENTS IN HOUSE OLD: (List additional household members on separate sheet of paper)
Name
Social Security #
Relationship to Applicant
Date of Birth
1.
2.
3.
4.
5.
LAST MONTH
(Gross Income}
Salary/Wages/Tips/self employment Income
$
Social Security (including AFDC & Welfare)
Pension or Annuities distributions
Interest & Dividends
Unemployment Compensation
Renta] Income
Alimony or Child Support
Other Sources
Total Income
5
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
S
All applicants MUST provide proof of ALL Income
No exceptions.
Check One:
Elderly
Disabled
Low Income
Tenant
(Please include copy of Driver's License or State ID with proof of age.)
(Please include medical certification of disability from Physician.)
(Please complete low income application as instructed.)
(Please include a copy of Rental Agreement and notarized Tenant Verification For
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
LOW-INCOME PROGRAM
2350 MARKET STREET
ST. LOUIS, MO 63103
FOR ADDITIONAL INFORMATION:
PHONE — 1-866-281-5737 or e-mail at
billingquest a,stlmsd.com
1 AUTHORIZE THE METROPOLITAN SAINT LOUIS SEWER DISTRICT (MSD) TO EXAMINE ANY FINANCIAL RECORDS THAT RELATE TO MY INCOME. 1
DECLARE UNDER PENALITIES OF PERJURY THAT THIS APPLICATION (INCLUDING ANY ACCOMPANYING SCHEDULES AND STATEMENT(S) 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
Revised 1110/1j
Date
OFFICE USE ONLY
Date Received:
Received by: Additional Documentation Requested:
Additional Documentation Received: Circle One.• Approved Denied By:
If Denied, State Reason: Program Start Date:
Entered by:
Postmar
Date:
Date: