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2. To print this application, please click on this link:
   Application for Low-Income Senior Citizen/Low-Income Disabled Citizen Reduced Rate Program

   Complete this form and return to the District either by mail or by dropping it off in the payment drop box. Don't forget to include your supporting documents!
4. Low-Income Senior Citizen/Low-Income Disabled Citizen Reduced Rate Program Application
   Applicants must meet the following qualifications and certify that:
6. 1) I am over the age of 61; AND
   Please provide a copy of your government-issued ID, such as a driver’s license or identification card.
8. Copy of government-issued ID
10. 2) I have a total annual gross income not exceeding $75,000 annually, including that of a spouse or any co-occupants(s); AND

    Please provide a copy of your most recent income tax return.; AND

12. Copy of most recent income tax return
14. 3) I already receive the property tax deferral/exemption for this property through Snohomish County.; AND
16. 4) I own and reside in the residence noted below.
20. -OR-
24. 1) I am permanently disabled at the time of this application; AND
    Please provide proof of disability, in the form of a payment statement for SSI or SSDI.
26. SSI/SSDI Payment Statement
28. 2) I have a total annual gross income not exceeding $75,000 annually, including that of a spouse or any co-occupant(s); AND

    Please provide a copy of your most recent income tax return.

30. Copy of most recent income tax return.
32. 3) I already receive the property tax deferral/exemption for this property through Snohomish County.; AND
34. 4) I own and reside in the residence noted below.
36. First Name*
37. Last Name*
39. Service Address*
41. City*
43. Account/Customer Number*
45. Phone Number*
47. Email Address
49. I agree to notify the District should I move from this property, or if my gross annual income exceeds the amount above. I further agree to provide the District with financial information to support my application, and agree to provide future income information if requested by the District to verify my eligibility. I acknowledge that information provided by me in support of my application is a public record and subject to public disclosure. I agree to waive any claim of confidentiality in any information provided and I agree to release Mukilteo Water & Wastewater District, and its employees, agents, officers, and Commissioners from any liability or claims, which might arise from the disclosure of such information to any other party or entity. I certify, under penalty of perjury, under the laws of the State of Washington, that the foregoing is true and correct.
51. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
53. Electronic Signature
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field