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2. Name*
3. Date of Birth*
   Date of Birth
5. Street Address*
6. City*
8. Street Address 2
9. Zip*
11. Please select the following exemption:*

    1. I do hereby certify that I am over the age of 65, and that the above address is my sole and exclusive residence.
13. I am also aware that by completing this certification I will receive a discounted rate of $6.25 on the Infrastructure Service Charge on my water billing account.
15. Sworn to this on*
    Sworn to this on
17. Driver's License Front*

    Upload your driver's license (Front)

18. Phone*
20. Name*

    DISCLAIMER: By typing your name here, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

21. Email Address*
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field