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2. APPLICATION FOR POLICE PROTECTION SURCHARGE RELIEF
4. PHYSICAL ADDRESS*
6. NAME*
7. PHONE NUMBER*
9. MAILING ADDRESS *
10. EMAIL ADDRESS
12. CITY *
13. STATE*
14. ZIP CODE*
16. 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.
    
18. DECLARED GROSS ANNUAL HOUSEHOLD INCOME (Maximum Annual Income $30,000)*
    The sum of Adjusted Gross Income as stated on your US Income Tax Return plus Social Security including Medicare Premium
20. REQUIRED ATTACHMENTS *
    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.
22. INCOME
    $30,001 +
    $25,001 - $30,000
    Less than $25,000
23. SURCHARGE DUE PER MONTH
    $20.00
    $10.00
    $ 0.00
25. 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.
27. I hereby attest that this application accurately reflects my annual income.*

    1. Yes
    2. No
29. 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.
31. Electronic Signature
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field