Penalty Waiver

Penalty Waiver

Account Number:

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.

Proof of Disability:

The undersigned hereby certifies that they are receiving monthly benefits from:

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.

Date:

Phone:

Email:

Service Address:

Address

Apt, suite, etc:

City

State

Zip Code

E-Signature: