chtest1

About You

Waster Hauler Account Number(Required)

How Can We Reach You?

Please share your current contact information, in case we need to reach out regarding your application. * Please note that your contact information will only be shared with the waste hauler indicated above. We never share or sell our client contact information.

Preferred Method of Contact

Your Phone(Required)

Best Time to Call You(Required)

Tell us about your household.

Please use the fields below to tell us your household size (all people living in your home) and either the annual gross (before taxes) income or your monthly gross (before taxes) income for your entire household. There is no need to fill in both Annual and Monthly Gross fields.

Household Size

Please enter a number from 1 to 15.

Total Household ANNUAL Gross (Before Taxes) Income

OR Total Household MONTHLY Gross (Before Taxes) Income

How do I know if I qualify?

There are currently two paths to qualify for this program. Please select the path below that applies to your household.

Above, you reported:

Household Size: —

Total Household Annual Gross (Before Taxes) Income: —

Total Household Monthly Gross (Before Taxes) Income: —

Find your household size in the first column, then compare your household’s total gross income before taxes with the annual or monthly limit shown. Your household may qualify if its income is at or below the listed amount.

Household Unit Size	Annual Income	Monthly Income
1	$38,385	$3,198.75
2	$50,196	$4,183.00
3	$62,006	$5,167.17
4	$73,817	$6,151.42
5	$85,627	$7,135.58
6	$97,438	$8,119.83
7	$99,652	$8,304.33
8	$101,867	$8,488.92
9	$104,081	$8,673.42
10	$106,296	$8,858.00
11	$108,510	$9,042.50
12	$110,825	$9,227.08
Each Additional Member	$2,215	$184.58

Anything else you want us to know?

Please use the space below to share any additional information you would like us to know about your household, circumstances, or application. This field is optional.

Signature (Please type your full name)(Required)

Test Hauler Form 1

About You

How Can We Reach You?

Tell us about your household.

How do I know if I qualify?