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FRANK G. JACKSON, MAYOR 19- CITY OF CLEVELAND, DEPARTMENT OF PUBLIC UTILITIES 20 HOMES I FAD WATER RATE APPLK AI I(.)N (AG I.65 R ,'!VERT'` NEW APPI..K ATION i�r_ RENEVvAL APP! KATION 2() ................ DISABILl EY WATFR RAPE APPLICATION (UNDER AGE Gi)' NEW APPLICATION or __............ PEN'r.:V1JAL APF> Ii: ATI )N APPLICANT NAME PERMANENT PARCEL NO. ADDRESS CI I Y AND ZIP CODE WATER ACCOUNT # FROM YOUR REAL. ESTAT E TAX BILL. DATE OF BIRTH PHONE NO. Adjusted Gross Income, Old Age and Survivors Benefits, Social .Security, other Retirement, Pension or Annuity, all interest and dividends fr0n) Whatever source ! tUSt be Included in total income. INCOME: 2016-$32,500; 2017-$33,000; APPLICAN I S 20_,...,_._.,.,_..,., ANNUAL INCOME 5...... SPOUSE'S 20 ANNUAL INCOME $ TOTAL 20 ANNUAL INCOME S 2018-$33,500` *Please inCiicate year and program discount for which you are applyinc). PROPERTY MUST BE OWNER OCCUPIED. TYPE OF PROPERTY (PLEASE CHECK ONE): SINGLE DOUBLE _--_- CONDOfvIINIUibl APARIMEN I WI I I II,' ...........1111_.. SUITES LEGAL INTEREST IN PROPERTY (PLEASE CHECK ONE..) DEED LAND CONTRACT PURCHASE AGREEMENT OTII E R Ali (i I PROOF) I AU IHOR17F T'HE. DIVISION OF WAT'E'R 1'0 EXAMINE. ANY FINANCIAL RE CORD`> 1 HAT REI AT E 10 MY INCOME, I DFCL.ARE UNDER PFNA[.IIFS' OF PER)URYIIIAI IMS RETURN OF CLAIM (INCLUDING ANY ACCONIPANYING SCI IEDULES AND SFAT EMENI(S HAS BEEN EXAMINED BY ME AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IS A TRUE, CORRECT AND COM PLFI.F RETURN & REPORT. APPLICANT AGREES TO OBSERVE ALL ORDINANCES AND RULES OF I HE DIVISION OF WATER REGARDING WATER SERVICE 1.0 i I ITS PROPERI Y. IF ANY STAT EMENT IS FALSIFIED, APPLICANT WIL.I. LOSE THE PRIVILEGE OF THE HOMESTEAD WATET RATE FOR TI TREE YEARS. IN THE EVENTTHE PROPER FY IS SOLD; APPLICANT OR HIS AGENT AGREES TO NO IFYI HE DIVISION OF WATER WHEN I`HE I I IL_E TRANSFERS. FOR RENEWAL APPLICATION PLEASE RE DURN BY MARCH 31'" ANNUALLY. DAfE S IG NAL U RE.._..._..._._.._._.__ ......... ---- .............. --- ... _...... PHYSICIAN'S STATEMENT - CERTIFICATE OF TOTAL DISABILITY IF UNDER 65 YEARS OF AGE "'PERMANEN'f LY AND TOTALLY DISABLED' MEANS A PERSON WI 10 FIAS, ON TE IE DATE OF APPLICATION, SOME IMPAIRMENT IN BODY OR MIND THAT MAKES ONE UNFI f TO WORK AT ANY SUBSTAN I IAL.I_Y REMUNERATIVE EMPL.OY><IEN I WHICH THE PERSON IS REASONABLY ABLE 10 PERFORM AND WHICH WILL, WITH REASONABLE PROBABILITY, CONTINUE FOR AN INDEFINITE PERIOD OF AT LEAST TWELVE !1'ION 11 IS WITHOUT ANY PRESENT INDICATION OF RECOVERY THEREFROM OR HAS BEEN CERTIFIED AS PERMANENTLY AND TOTALLY DISABLED BY A STATE OR FEDERAL AGENCY HAVING 1-1 IF FUNCTION Of SO CLASSIFYING PERSONS" (R.C. 32 3.1 l ) I (WE) HEREBY CERTIFY'I HAT WAS, AS OF IANUARY 1 .111.1.._._.. __AND IS NOW TO TALLY AND PERMANENTLY DISABI..E.D BYVIRTUE OF PHYSICAL DISABILITY OR MENTAL DISABII._ITY PHYSICIANS/PSYCHOLOGIST SIGNA'EURF LICENSE NO. .... ............ _.... _...... ................. PRIN f NAME OF PERSON SIGNING: ADDRLSS-SIRE:E:I NO, - CITY - ZIPC:ODE A=PE2C)VAI.. C:C?NTINGEN E i1PC)N DOCTOR'S COMPLETION OF THIS PORI ION, PLEASE RETAIN YELLOW COPY FOR YOUR RECORDS. DIVISION OF WATER HOMESTEAD UNIT P.O. BOX 94687 CLEVELAND, OH 44101-4687 FOR ADDITIONAL. INFORMATION: (2 16) 664 3130 C1fY OF CLEVELAND MISSION STATEMENT e ate viz,ml;ted to Imprcvt g Vie, It ali y ut hfe In !Y t 1tv Of , IPvriana by treng'hemnu out ne'!ghborl,w�,d:, d -liven } ii;:enc .Frs;ce<. embraon,T the :f,nd m,kir y INhl"h to r,c ,..; k r-vze a t,nvly, dhon au 'y nL:ry I It d ,row "Id.