SPIPA WATER ASSISTANCE PROGRAM

Please fill out this application completely. All information requested is necessary to process your application. The information you provide is confidential. Please be sure to attach documentation of water and Income for the months of June, July, and August 2021.

LIST ALL MEMBERS IN YOUR HOUSEHOLD, INCLUDING YOURSELF: (use back if needed for more space) Household membersDate of BirthEnrollment # Social Security NumberRelationship

ELIGIBILITY INFORMATION: list monthly amount of income sources(s) that applies to your household. Mark N/A for any income source that does not apply to you. Failure to report every income source may result in denial of LIHEAP benefits.

ELIGIBILITY INFORMATION: List monthly amount of income source(s) that applies to your household. Mark N/A for any income source that does not apply to you. Failure to report every income source may result in denial of LIHEAP benefits. 

Have you applied for and/or received any assistance from any other organization in the past 6 months

I realize that any false statement or misrepresentation knowingly made by me for the purpose of obtaining assistance under this program may result in my being denied assistance and/or may result in action against me which could subject me to Civil and/or Criminal penalties. I understand that by signing this application/certification, I give up my consent to any investigation to verify or confirm the information I have given. In addition, I also authorize SPIPA to verify utility costs consumption rate.