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Hi-Desert Water District
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Water Shutoff Policy Request Form
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Account Number (if available)
ARE YOU THE OWNER OF THE ACCOUNT?
Mobile Home Unit
Please select all that apply to determine eligibility. Documents proving eligibility will be asked upon submitting a request.
Health Related Issues
Recipient of CalWORKs, CalFresh, Medi-Cal, Supplemental Security, Income/State Supplementary Payment Program, or California Special Supplemental Nutrition Program for Women, Infants, and Children
Annual Household Income is less than 200% of Federal Poverty Level
Request for Alternative Payment Arrangement
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