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Fixed Income Application
Application for Fixed Income
"
*
" indicates required fields
CUSTOMER INFORMATION
Name
*
First
Last
Physical Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mailing Address (if different from Physical Address)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
*
Cell Phone
*
Alabaster Water Board Customer for 12 months or more?
Yes
No
If you prefer Alabaster Water Board to speak to a relative in regard to this application, please fill out the information below. This does not give this person permission to make any changes to your account.
Name
Relationship to you
Daytime Phone Number
HOUSEHOLD INFORMATION
Number of people living in household (Adults 18 and over)
*
Select Amount
1
2
3
4
5+
Please add every adult 18 and over
Name
Date of Birth
Employer
Add
Remove
Income Sources (Please check all sources of income received by residents of this household)
*
Wages/Salaries
Unemployment Benefits
Rental Income
Interest/Dividends
Social Security, SSI, SSP
Pension/Private Retirement
Disability Payments
Workers Compensation
Child/Spouse Support
Insurance/Legal Settlements
Other
Please list other income
*
REQUIRED DOCUMENTS
Please provide a copy of the following documents that were issued to you or any other current resident of the property above. **Failure to include requested documents will result in a delayed review or denied application**
Copy of current Social Security Award Letter
*
Accepted file types: jpg, jpeg, png, pdf, doc, Max. file size: 16 MB.
OR a copy of current Annual Statement from Social Security
Copy of Valid Driver's License
*
Accepted file types: jpg, jpeg, png, pdf, doc, Max. file size: 16 MB.
Copy of 2 Consecutive Monthly Bank Statements
*
Drop files here or
Select files
Max. file size: 5 MB.
For ALL Accounts of ALL household residents of property (checking, savings, share) or 2 Consecutive Statements from your Direct Express Card that your check is applied to. August 2022 and September 2022 OR September 2022 and October 2022 OR October 2022 and November 2022
The undersigned customer of the Alabaster Water Board, having applied for Fixed Income Rates, hereby states under oath that the household income for the residence receiving service is solely from Social Security Retirement or Social Security Disability income benefits. The undersigned acknowledges that receipt of income from other sources may result in the disqualification of fixed income rates and agrees to inform Alabaster Water Board of any changes in household income within 30 days of such change. The undersigned further acknowledges that the fixed income rate shall be
applied for annually between November 1st and December 31st
and will not be applied retroactively. The undersigned specifically agrees that if it is later determined that he or she has knowingly given false or misleading information to qualify for the fixed income rate, the customer shall immediately lose the reduced base rate benefit, retroactive to the time the benefit was granted, and shall be required to pay immediately to the Alabaster Water Board the total benefit amount received as a result of false or misleading information. I state that the information I have provided in this application is true and correct. I agree to provide the necessary information requested to process this application. I accept the above terms and acknowledge that Alabaster Water Board may amend the rules governing the Fixed Income Rate program at any time.
Please Type Name
Date
*
MM slash DD slash YYYY
Signature
*
Δ
ALABASTER WATER BOARD ANNOUNCES ANNUAL OPEN ENROLLMENT FOR REDUCED RATE PROGRAM NOVEMBER 1, 2024 – DECEMBER 31, 2024 Alabaster...
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