Please select which program you are enrolled in and aach proof of enrollment: Bureau of Indian Affairs General Assistance Low Income Home Energy Assistance Program (LIHEAP) CalFresh (Food Stamps) Medi-Cal/Medicaid CalWORKs (TANF)[1] or Tribal TANF Medi-Cal for Families A & B CARE Program through SCE or SoCal Gas Naonal School Lunch Program (NSLP) Head Start Income Eligible – Tribal Only Supplemental Security Income (SSI) Women, Infants & Children (WIC) Other: I do not have proof of enrollment. However, I declare that total household income is less than 200 percent of the federal poverty level.* Income Certification Form EMWD Assist provides low-income customers who also have a signed medical cerficate from their primary care provider with extended payment amorzaon opons to help them avoid disconnuaon of residenal water service. Customer Informaon Customer Name EMWD Account Number Street Address City State Zip Code Phone Number Alternate Phone Number *Guidelines effecve June 1, 2019 to May 31, 2020. Upper limit calculaon is equal to 200 percent of Federal Poverty Guidelines. If customer is recently unemployed, the total annual household income will be calculated from the date of customer’s unemployment. Customer Signature Date Aenon: Please do not submit any sensive data such as social security number, drivers license number, birthdate, medical condion, or other protected data. EMWD reserves the right to verify informaon submied on this form.

Income Certification FormIncome Certification Form ... y t i C e t a t S e d o C p i Z Phone Number Alternate Phone Number *Guidelines effective June 1, 2019 to May 31, 2020. Upper

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Page 1: Income Certification FormIncome Certification Form ... y t i C e t a t S e d o C p i Z Phone Number Alternate Phone Number *Guidelines effective June 1, 2019 to May 31, 2020. Upper

Please select which program you are enrolled in and attach proof of enrollment:

Bureau of Indian Affairs General Assistance Low Income Home Energy Assistance Program (LIHEAP)

CalFresh (Food Stamps) Medi-Cal/Medicaid

CalWORKs (TANF)[1] or Tribal TANF Medi-Cal for Families A & B

CARE Program through SCE or SoCal Gas National School Lunch Program (NSLP)

Head Start Income Eligible – Tribal Only Supplemental Security Income (SSI)

Women, Infants & Children (WIC)

Other: I do not have proof of enrollment. However, I declare that total household income is less than 200 percent of the federal poverty level.*

Income Certification FormEMWD Assist provides low-income customers who also have a signed medical certificate from their primary care provider with extended payment amortization options to help them avoid discontinuation of residential water service.

Customer Information

Customer Name EMWD Account Number

Street Address

City State Zip Code

Phone Number Alternate Phone Number

*Guidelines effective June 1, 2019 to May 31, 2020. Upper limit calculation is equal to 200 percent of Federal Poverty Guidelines. If customer is recently unemployed, the total annual household income will be calculated from the date of customer’s unemployment.

Customer Signature Date

Attention: Please do not submit any sensitive data such as social security number, drivers license number, birthdate, medical condition, or other protected data. EMWD reserves the right to verify information submitted on this form.