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Forms on the left are PDF forms to be printed, filled out and delivered to City Hall. The forms below can be completed and submitted online. As time allows we will be converting many of the PDF forms to online submission.
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Police Protection Surcharge Relief Application

  1. APPLICATION FOR POLICE PROTECTION SURCHARGE RELIEF

  2. Qualifications:

    1. A residential unit's total gross annual income shall meet the income guidelines below.
    2. The discount shall only apply to the applicant's physical address.
    3. The application for Surcharge Discount must be filed annually and approved by the Public Safety Committee or their designee.
    4. The Public Safety Committee may grant exemptions to the income limitations provided justification can be proven.

  3. The sum of Adjusted Gross Income as stated on your US Income Tax Return plus Social Security including Medicare Premium

  4. Copies of documents that pertain to your declared income must be attached to this application including but not limited to:
    1. Prior Years US Income Tax Return - First page (only) showing Adjusted Gross Income
    2. Social Security Statement
    3. Interest or other income statement(s)

    If you are unable to scan in and attach the required documentation, please submit a hard copy application to City Hall.

  5. INCOME

    $30,001 +
    $25,001 - $30,000
    Less than $25,000

  6. SURCHARGE DUE PER MONTH

    $20.00
    $10.00
    $ 0.00

  7. Improper Application

    Any person who falsely states any fact to acquire the benefits of this application, or who receives the benefit of this application with knowledge that he does not qualify, is guilty of a misdemeanor and shall be punished by a fine not to exceed five hundred dollars ($500.00) or by imprisonment for a period not to exceed sixty (60) days or by both such fine and imprisonment.

  8. I hereby attest that this application accurately reflects my annual income.*

  9. 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.

  10. Leave This Blank:

  11. This field is not part of the form submission.