KCMO Water Services Fund Application

KCMO Water Services Fund Pre-Application

This fund is for KCMO Water Department customers ONLY! You can apply online here or report directly to an agency. To be eligible for this fund you must meet the following requirements: 1. Have an active account 2. Have made a payment on your account within the last 30 - 60 days 3. Below the 185% Federal Poverty Income Limit. Note: Your application will not be processed online, you must report to an agency/authorized representative to complete!
Name of Applicant*

PrefixFirst NameMiddle NameLast Name
E-mail of Applicant*
example@example.com
Phone number of Applicant*
Mobile Phone number of Applicant
Address of Applicant*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth of Applicant*

MonthDayYear
Social Security Number (All sensitive data is securely stored only with Jot Form and Mid America Assistance Coalition and is not shared with any other entities.)*
Is your water service currently ACTIVE or DISCONNECTED?*

ActiveDisconnected
Have you used the KC Water Services Fund before?*

YesNo
Are you currently applying for this fund at a Utility Assistance Event? (Ex: Evergy Connect Center/KC Water Department/Or other social services agency?*

YesNo
How much is your PAST DUE water bill?*
KCMO Water Services Account Number*

KC Water Services Fund Application

Please Upload a Picture of Your ID and Most Recent Water Bill
Upload ID (State ID/Driver's License)*

Cancelof
Upload Your Most Recent Bill (30 Days or Less - NO DISCONNECTED ACCOUNTS)*

Cancelof

Employment

Income Assessment
Are you currently employed?*

YesNo
What is your TOTAL monthly income? (including all adults in the household)*
Example ($1,200 per month or input the amount you make each pay period - weekly/biweekly)
Total # of members living in your household? *
If no income, please list "0" (Individual agency will verify if there is no income)
What bills do you currently pay within your household?
I certify that the information provided on this application is complete, accurate and true. All recorded responsed are subject to verification from the individual agencies and case managers.

Any false or inaccurate statements provided on this application will result in being banned from future use of this fund which is provided by the KCMO Water Department and is subject to approval and verification.

Please note that all responses recorded will only be shared with KCMO Water Department, partner agencies, and MAAC but will not be shared to anyone else and is kept strictly confidential.
I agree that the information herein are true and correct*

Yes
Signature*

Clear
Should be Empty:

KCMO Water Services Fund Pre-Application