Low-Income Application

A "low-income customer" is a PUD utility customer who meets the requirements as set forth in section 10.6 of the Jefferson County PUD Customer Service Policy

PUD Account Number(s)

Which Services do you Receive From the PUD?
Check All that Apply
Which Programs are You Applying For?
Check all that apply.
Electrical Service Account Number
Water & Sewer Service Account Number
Name (Primary account holder)
Service Address
Is the mailing address different from the service address?
I have been at this address for at least 12 months and would like more information about Budget Billing

Primary - Gross income for the last three months

Housing
Income/Benefits

Secondary (18 and older) - Gross income for the previous three months

Name (Secondary Account Holder)
Income/Benefits
Is there an additional household member (18 and older) at this address?

Additional Household Member (18 and older) - Gross income for the previous three months

Name
Income/Benefits
Is there an additional household member (18 and older) at this address?

Additional Household Member (18 and older) - Gross income for the previous three months

Name
Income/Benefits
Is there an additional household member (18 and older) at this address?

Additional Household Member (18 and older) - Gross income for the previous three months

Name
Income/Benefits
Is there an additional household member (18 and older) at this address?

Additional Household Member (18 and older) - Gross income for the previous three months

Name
Income/Benefits
Is there an additional household member (18 and older) at this address?

Verification Document Uploads

In order for Jefferson County PUD to consider your application for Low Income Program benefits, please provide copies of the documents listed below along with a completed Low Income Program Application. Incomplete applications will not be processed. For questions, contact our Customer Service Program Specialist by calling (360) 385-8357 or via email at: dmcknight@jeffpud.org

Identification:

  • Photo ID for ALL household members 18 or older
  • Verification of ALL children living in the household (one of the following)
    • Photo ID (School ID, state ID, driver’s license, or passport)
Drop files here or
Accepted file types: pdf, jpg, jpeg, doc, docx, png, Max. file size: 128 MB.

    Income Statements

    • Verification of Income for ALL household members of the four months prior to your appointment
      • Earned Income - Previous three month's paystubs
      • Unemployment - Printouts or Stubs
      • Interest Income-Bank Statements
      • Copy of Prior Year's Taxes (1040, 1099, including W-2s)
      • SSI Social Security, VA Benefits, or Pension - Determination letter or DSHS statements
      • TANF or ABD - Determination letter or DSHS statements
      • Child Support received or paid - DSHS statement or processed check copies

    ***Primary applicant must be a responsible party on the PUD account that will be billed at the reduced low-income rate.

    Drop files here or
    Accepted file types: pdf, jpg, jpeg, doc, docx, png, Max. file size: 128 MB.

      Once application has been submitted, we will reach out to you to discuss how to submit income verification.


      **Primary applicant must be a responsible party on the PUD account that will be billed at the reduced low-income rate.


      This claim is subject to audit: Any person willfully giving false information on this application shall be subject to the perjury laws of the State of Washington. Any exemption granted through erroneous information provided by the applicant shall: be subject to the correct fee being assessed, plus a 100 percent penalty.


      Appeal on Denial of Claim: If the applicant does not meet the qualification as provided by the District guidelines, the applicant may request an appeal hearing as set forth in section 12.2 of the Jefferson County PUD No. 1 Customer Service Policy.


      I certify under perjury under laws of the State of Washington that all information I have provided in order to apply for the PUD No. 1 of Jefferson County's Rate Reduction Program is true, complete and correct.

      Clear Signature
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      Clear Signature
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      This field is for validation purposes and should be left unchanged.