Detroit Water Fund Application Section 2 (Non

DO NOT SUBMIT THIS APPLICATION UNLESS INSTRUCTED TO DO SO BY A DWSD REPRESENTATIVE WHO HAS
PRE-QUALIFIED YOUR HOUSEHOLD
Detroit Water Fund Application
Section 2
(Non-LSP Enrolled Customers Only)
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Application Checklist
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□ Contact DWSD for payment plan and pay 10% of past due balance. If you are already on a payment
plan you must still contact DWSD first for Pre-qualification.
□ Attach Proof of Identification showing address (Driver’s License or Government issued Identification) to
application.
□ Attach Proof of Income for all Household Members. This could include copies/photos of:
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Pay stubs
Tax forms
W-2’s
SSI/SDA
FIA Payments
Pension/Retirement
Social Security
*Applications lacking all required documentation will be considered incomplete. Complete
applications will be considered on a first come, first serve basis.
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Please fill out the attached application and mail, fax or email along with copy of
account holder’s identification and proof of income for each household member
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UWSEM
660 Woodward, Ste. 300
Detroit, MI 48226
Attention: Detroit Water Fund
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Fax: 313-226-9208
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Email: [email protected]
DETROIT WATER FUND APPLICATION
SECTION 2: PRIMARY APPLICANT INFORMATION
1. First Name:
Last Name: _________
! Social Security Number: ______
(MANDATORY)
_______
*Acct No.
2 Service Address :
4. Primary Phone:
City:
Permission to receive texts
Detroit
Zip:________
Email address:
!5. Household Information
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Name
SSN
!1.
!2.
!3.
!4.
!5.
!6.
!7.
!8.
!9.
SIGNATURE REQUIREMENT –
Income Source 1
Income Source2
Income Source3
Income
Source
Income
Source
Income
Source
Monthly
Amount
Monthly
Amount
Monthly
Amount
Please sign below. Otherwise, this application will be incomplete
I understand failure to provide the below information may result in denial of my application. I affirm that United Way has certified all information contained
within this application and that it is the sole purpose of determining my eligibility for enrollment and participation in the Detroit Water Fund. I affirm the
information provided is true, subject to verification, all household members’ information can be shared, and if false, I will be denied eligibility. I authorize to
this agency, United Way, and utility vendors to request and receive information from other parties as necessary to reach a determination on my eligibility for
the DWF Plan. I understand that my customer information will be shared with the State and Federal agencies to meet the assistance guidelines.
Additionally, a representative may call at my home and may contact other people in order to verify my eligibility for enrollment. I have read, understand, and
agree to these conditions and requirements. I understand that there are limited funds available, and that eligibility is no guarantee of receiving assistance. I
understand that assistance is provided on a first come, first serve basis.
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Signature of Applicant
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UWSEM STAFF ONLY: ____LSP Verified ___Elig
Print Name
Date
_____Not Elig ____QuickForm Only ____No QF _____Inc
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PLEASE ATTACH PROOF OF IDENTIFICATION AND ALL HOUSEHOLD
INCOME
UWSEM STAFF ONLY: ____LSP Verified ___Elig
_____Not Elig ____QuickForm Only ____No QF _____Inc

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