OFFICE USE ONLY
Date/Time Submitted: Income Qualified Not Income Qualified
2018 Assistance Program Application
Verifying household income is the first step in qualifying for the Thornton financial assistance programs, including Thornton Water Assistance, Tax Rebate for Elderly Persons and the Reduced Rate Assistance for recreation facilities and programs. Copies of income verification must be submitted with this application. Please provide the documents in one of the following options: 1) A current benefit statement if your family is receiving SNAP, TANF, WIC, LEAP or Medicaid. 2) One month of paystubs and/or other income for everyone age 18 or older living in the house PLUS a current monthly bank statement for the household or individuals. 3) A tax return for the 2017 year PLUS a current monthly bank statement. 4) In certain situations, we can accept two recent, consecutive bank statements. Full Name: Street Address: City, ZIP Code: Years/Months at Current Address: Daytime Contact Telephone Number:
Email:
ALL HOUSEHOLD MEMBERS AND INCOME: CITY YOUR HOUSEHOLD = you plus all the people who live in the house with you. INCOME = all money a person earns or receives, such as wages, unemployment compensation, social security or STAFF disability income, pension or retirement payments, interest on investments or savings accounts, child support, ONLY alimony, loans or any other money received. Type of Relationship Gross ADDRESS Full Name Date of Birth Age Income to You Monthly Amount VERIFIED Self
I certify that the information provided on and with this application is true and correct to the best of my knowledge. I understand that if I have provided false or misleading information or tampered with a city meter, I will be denied assistance or expected to repay the credit, which will be billed through my water account. I authorize city of Thornton staff to verify all information provided above. I will comply with all city policies and ordinances related to these programs. I understand that assistance will be provided only once in a calendar year and to the extent funds are available. APPLICANT SIGNATURE
303-538-7360
DATE
[email protected]
AFFIDAVIT The resident/water customer must complete the following statement and sign and date. I, ________________________________, swear or affirm under penalty of perjury under the laws of the State of Colorado that: (Check ONE.) I am a United States citizen.
I am a permanent resident of the United States.
I am lawfully present in the United States pursuant to Federal law.
This sworn statement is required by Colorado law, because I have applied for a public benefit. The law (C.R.S. 24-76.5102) requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503, and it shall constitute a separate criminal offense each time a public benefit is fraudulently received. APPLICANT SIGNATURE DATE FOR CITY STAFF ONLY
A copy of the identification MUST accompany this application. The applicant seeking to apply for public benefits demonstrates lawful presence by presenting one of the following identification documents. Valid Colorado driver’s license
Certificate of Degree of Indian or Alaskan Native Blood
Colorado ID card or Military ID card
Visa or other proof of legally residing in the United States
Passport Is the applicant an individual metered Thornton Water customer?
Yes
No
Has the applicant received water assistance this calendar year?
Yes
No
Is the applicant a Thornton resident? (Address verified through property brower map.)
Yes
No
Does applicant rent or own their home. (Verified through County records.)
Rent
Own
Date referred from Utility Billing: ___________________
Programs qualified for:
Water Assistance
Senior Tax Rebate
Reduced Recreation Fee
NAME OF REVIEWER
NAME OF 2ND AUTHORIZER
303-538-7360
DATE
[email protected]
