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Water Shutoff Policy Request Form
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Account Number (if available)
ARE YOU THE OWNER OF THE ACCOUNT?
Yes
No
SELECT ONE:
Owner Occupied
Renter
PROPERTY TYPE:
Single-Family Home
Apartment
Mobile Home Unit
Name
Email Address
Property Address
City
State
Zip Code
Phone Number
Fax Number
ELIGIBILITY REQUIREMENTS
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
ADDITIONAL COMMENTS:
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