City of Marysville
Application for Senior Citizen Assistance on Water/Sewer Usage Bills
Name:___________________________________________ Date: ________________________
Address: _________________________________________
Tax Description number: _____________________________
Requirements:
1. I live in the house at the above address.
2. I own the house and land at the above address.
3. This is a single family residence from which I derive no
income. (Rented rooms, apartments, etc.)
4. I am 65 years of age or older.
5. Itemize your household income (or attach a copy
of last year's MI-1040CR).
| a. wages, salaries, tips, etc. | __________________ |
| b. net business, farm, rental income. | __________________ |
| c. Income from annuities, estates, trusts, partnerships, subchapter "S" corporations. | __________________ |
| d. Dividends and interest (including interest from U.S. Securities, state and municipal bonds). | __________________ |
| e. Social Security, Veteran's Pension, Railroad Retirement. | __________________ |
| f. All other pensions. | __________________ |
| g. Total cash public assistance. | __________________ |
| h. All other income. | __________________ |
|
Total Household Income: |
__________________ |
I, _______________________________________, do hereby certify that the above information is true and correct. I further state that I will report any material changes to the above information directly to the City of Marysville.
Signature: _________________________________________
Telephone #______________________________
TOTAL HOUSEHOLD INCOME LIMIT - $20,000.00
WATER/SEWER DISCOUNT - 30%