Bay Restoration Fee Financial Hardship Exemption Application

2. Town Contact Information
   110 South Main Street
   P.O. Box 50
   Mount Airy, MD 21771
   
   Phone: 301-829-1424
   Fax: 301-829-1259
3. Note
   For the Tax Year: July 1, 2019– June 30, 2020. A new application must be completed every year.
5. Name*
6. Account Number
8. Mailing Address*
10. City
11. State
12. Zip Code
14. Phone Number
15. Fax Number
19. Service Address (if different than mailing address)
21. City
22. State
23. Zip Code
25. 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.
27. Applicant Description

    1. Receive supplemental security income (SSI) or food stamps
    2. Receive veterans or social security disability benefits
    3. Receive energy assistance subsidy
    4. Receive State of Maryland Homeowner Property Tax Credit
    5. Meet Income Eligibility Requirements
29. File Upload 1
30. File Upload 3
32. File Upload 2
33. File Upload 4
35. Income Eligibility Limits Effective July 1, 2019 - June 30, 2020
37. Household Size
    1
    2
    3
    4
    5
    6
    for each addt'l person, add
38. Maximum Gross Monthly Income
    $1,821
    $2,466
    $3,111
    $3,755
    $4,400
    $5,044
    $645
39. Maximum Gross Yearly Income
    $21,858
    $29,593
    $37,328
    $45,063
    $52,798
    $60,268
    $7.740
41. 
    Source for Data:
    Maryland Department of Human Resources / Office of Home Energy Programs.
43. Applicant's eSignature*
    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.
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field