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2. Confidentiality

   The information provided will be kept confidential and used only for the purpose of determining eligibility for financial assistance. For grant consideration, applications must be completed fully by an account or property owner and signed.

6. Applicant Name:*
7. Wellington Utility Acct #:
9. Address*
11. Phone Number:*
12. Email Address:*
14. Do you rent or own your residence?*

    1. Rent
    2. Own
15. Is this your primary residence?*

    1. Yes
    2. No
19. Briefly describe why you are in need of assistance with your Wellington utility payment:*
23. Eligibility Certification

    Applicants must certify they meet the following criteria – initials required on each line:

25. Is a residential water utility customer of the Town of Wellington. (Must be an account or property owner.)*
26. Has no violations of record for tampering with meters/pit.*
27. Has a current hardship creating inability to pay and must provide documentation supporting hardship (i.e., paystub with reduction of hours, medical bill, etc.).*
29. Will sign up for a water use audit or training provided by the Town to help reduce water consumption/waste. (Link to training video available below)*
30. Will reach a utility balance of $0 upon application of the funding, but if the balance will be in excess of the grant, the applicant must enter into an agreement to reach a $0 balance within two months.*
31. Will keep their account current after the application of funding.*
33. Training video
    View training video at: https://www.youtube.com/watch?v=RnjGlOX6dKY
35. Supporting Documentation*

    Upload documentation supporting hardship here.

39. Application

    Upon receipt of a completed application that includes eligibility certification and all required documentation, the grant will apply a credit to the applicant's utility account in an amount not to exceed $300 in a calendar year for each household. Applications for funds will be considered on a first-come, first-qualified, first served basis and will only be available if appropriated funding is available.

    
    

     I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. 

41. First Name*
42. Last Name*
43. Date*
45. 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.
47. Electronic Signature*
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field