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Bay Restoration Fee Financial Hardship Exemption Application

  1. Town Contact Information

    110 South Main Street
    P.O. Box 50
    Mount Airy, MD 21771

    Phone: 301-829-1424
    Fax: 301-829-1259

  2. Note

    A new application must be completed every year.

  3. Eligibility Requirements

    1. The property must receive an individual quarterly water/wastewater usage bill.
    2. Applicant must reside at property and be able to provide proof of water/wastewater bill payment.
    3. Applicant must meet at least 2 of the following conditions to be eligible for the exemption. Attach a copy of appropriate documentation that verifies compliance with any checked conditions.

  4. Applicant Description

  5. Income Eligibility Limits Effective July 1, 2018 - June 30, 2019

  6. Household Size

    1
    2
    3
    4
    5
    6
    7
    8

  7. Maximum Gross Monthly Income

    $1,770
    $2,400
    $3,030
    $3,660
    $4,290
    $4,920
    $5,550
    $6,180

  8. Maximum Gross Yearly Income

    $21,245
    $28,805
    $36,365
    $43,925
    $51,485
    $59,045
    $66,605
    $74,165

  9. One Person's Amount

    For each additional person in your household, add $630 for monthly income and $7,560 for yearly income.

    Source for Data:
    Maryland Department of Human Resources / Office of Home Energy Programs.

  10. I declare under the penalties of perjury, that the information provided on this application is, to the best of my knowledge and belief, true, correct, and complete.

    By typing your name, 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.

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