Fixed Income Application |

CUSTOMER INFORMATION

Name*

First Last

Physical Address*

Street Address City State ZIP Code

Mailing Address (if different from Physical Address)

Street Address City State ZIP Code

Home Phone*

Cell Phone*

Alabaster Water Board Customer for 12 months or more?

Yes

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)*

Please add every adult 18 and over

Name

Date of Birth

Employer

Income Sources (Please check all sources of income received by residents of this household)*

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

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*

Signature*

Fixed Income Application

Application for Fixed Income

CUSTOMER INFORMATION

HOUSEHOLD INFORMATION

REQUIRED DOCUMENTS