Application for Reduced Water/Sewer Base Fee
Senior and/or Disabled Citizen

I hereby request that the Douglasville – Douglas County Water and Sewer Authority (the “Authority”) review my application for a courtesy fixed reduction of the water/sewer base fee available to qualifying senior and/or disabled citizens in accordance with the Authority’s Rules and Regulations. As used in this application, “I, “me,” and “my” mean the customer of record signing this form for the Authority account identified above.

By signing below, I understand and acknowledge that any water/sewer base fee reduction approved will be granted and maintained only if I qualify under, and continue meet, the eligibility requirements set forth in the Authority’s Rules and Regulations and applicable policies as stated herein. In addition to meeting the eligibility requirements, I acknowledge that I must cooperate fully with the Authority in its review and provide all information and documentation requested by the Authority, in a form acceptable to the Authority.  I further acknowledge that submission of this Application and Affidavit does not guarantee approval and that my Application will be reviewed only upon the Authority’s receipt of both the completed Application and Affidavit.

I understand that it is my duty to notify the Authority immediately if any circumstances occur which render me ineligible for the base fee reduction, including but not limited to: (a) moving from and no longer occupying the service location as my permanent residence, even if I retain ownership, or (b) an increase in gross household income above the applicable HUD Income Limit, which is updated annually. In consideration of receiving the courtesy base fee reduction, I agree to fully cooperate with submitting updated information and a new Affidavit upon any request by the Authority.

I certify that the information I provide is true and correct, and I understand that providing untrue or incorrect information or failure to cooperate with future Authority requests may result in denial of my application or discontinuation of the courtesy base fee reduction, in accordance with the Authority’s Rules and Regulations. I agree that this Application may be stored electronically and any electronic copy, including the signatures thereto, will be deemed an original, admissible, and enforceable to the same extent as a paper original.