Income Discount Application

Income Verification*
Main Income
Other Income
Your application will not be considered complete until our department has received your supporting documents. Please attest that supporting documents have been sent to verify@bentonrea.org

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Supporting Documents*

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I, the undersigned, hereby certify that the information provided by me above, and any additional associated Power to Care Bill Assistance documents submitted by me, are complete and accurate to the best of my knowledge*

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I, the undersigned, hereby certify that the information provided by me above, and any additional associated Power to Care Bill Assistance documents submitted by me, are complete and accurate to the best of my knowledge. Signature*
Date*

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Date
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Income Qualified Senior or Disabled Member Discount