Sunrise Water Authority Assistance Application Form

Prefer to download, print, and mail the application?
Download: Sunrise Water Authority Assistance Application

Encrypted Sunrise Water Authority Assistance Application Form

Please make sure you upload your income documents at the end of this form – a list is provided below. All data on this form is encrypted for your security.

Name

This field is for validation purposes and should be left unchanged.

Your name(Required)

First Last

Phone

(###) ###-####

Your email(Required)

Enter Email Confirm Email

Physical Address(Required)

Street Address Address Line 2 City State ZIP Code

Mailing Address (If Different from above)

Street Address Address Line 2 City State ZIP Code

Please provide the gross income (before taxes) and income source for all household members age 18 or older, along with documentation covering the last 30 days.

The definition of “gross (before taxes) household income” is all money and noncash benefits, available for living expenses, from all sources, both taxable and nontaxable, before deductions, for all people who live in the home. Examples of income documentation includes, but is not limited to the following:

Paycheck stubs
Unemployment verification letter, Social Security benefit award letter, TANF (Temporary Assistance for Needy Families) print out, Child Support print out, Proof of Veterans benefits, pensions, retirement, etc.
Written statement of Self-Employment detailing gross receipts and business expenses
Written statement with details of any additional cash income
If you have no income, please provide a written statement of how you sustain yourself financially, covering essentials like food and housing.

Your age

Your income (from last month)

Your income source(s)

Number of people living in household(Required)

Please enter a number from 1 to 8.

Household member 2

Household member 2: Name

First Last

Household member 2: Age

Household member 2: Income Amount

Household member 2: Income Source(s)

Household member 3

Household member 3: Name

First Last

Household member 3: Age

Household member 3: Income amount

Household member 3: Income source(s)

Household member 4

Household member 4: Name

First Last

Household member 4: Age

Household member 4: Income amount

Household member 4: Income source(s)

Household member 5

Household member 5: Name

First Last

Household member 5: Age

Household member 5: Income amount

Household member 5: Income source(s)

Household member 6

Household member 6: Name

First Last

Household member 6: Age

Household member 6: Income Amount

Household member 6: Income source(s)

Household member 7

Household member 7: Name

First Last

Household member 7: Age

Household member 7: Income Amount

Household member 7: Income source(s)

Household member 8

Household member 8: Name

First Last

Household member 8: Age

Household member 8: Income amount

Household member 8: Income source(s)

Total income and file uploads

Total household income (calculated from amounts entered above)

File

Drop files here or

Max. file size: 16 MB, Max. files: 10.

Is there anything else you want us to know about your situation? Tell us in the space below.

Declaration:(Required)

I agree to inform Sunrise Water Authority if my household no longer qualifies for the Income-Qualified Assistance

True and correct:(Required)

I understand under penalty of perjury under the laws of the State of Oregon that the information I provided in this application is true and correct.

Signature(Required)

Sunrise Water Authority Assistance Application Form

Prefer to download, print, and mail the application? Download: Sunrise Water Authority Assistance Application

Encrypted Sunrise Water Authority Assistance Application Form

Household member 2

Household member 3

Household member 4

Household member 5

Household member 6

Household member 7

Household member 8

Total income and file uploads

Prefer to download, print, and mail the application?
Download: Sunrise Water Authority Assistance Application