Penalty Waiver

Pursuant to City Ordinance No. 3439, the ten (10) percent additional charge (penalty)
may be waived to certain users where the primary income for the household is derived
from monthly funds received as a benefit or aid from a state or federal agency.
Examples of primary income include Social Security Benefits (SS), Social Security
Income (SSI), Veterans Administration Disability Benefits (VA), Aid to Families with
Dependent Children (AFDC), and aid to the Aged, Blind and Disabled (AABD).

This form must be submitted to the business office of Springdale Water
Utilities with current proof of disability benefits.

which qualifies for a waiver of the penalty charge provided in City Ordinance No. 3439.
Furthermore, the undersigned understands that this penalty waiver does not relieve me
from paying the gross amount by the due date of each month.