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SAN JOSE MUNICIPAL WATER LOW INCOME AND VULNERABLE CUSTOMER CERTIFICATION FORM

INSTRUCTIONS
Please fill out this form to establish low income and/or vulnerable customer status. Established Low Income and Vulnerable status expires after one year, after which the customer must recertify to retain certification.

Note: If you are unable to complete the online form, customers may also mail the completed form and supporting documentation to:
San José City Hall – Finance Department Utility Billing
200 East Santa Clara Street
San José, CA 95113

Customers who qualify as low income must declare under the penalty of perjury that household annual income is less than 200 percent of the Federal poverty level.

For current Federal poverty level guidelines please visit:  https://www.healthcare.gov/glossary/federal-poverty-level-fpl/

Customers may provide documentation to demonstrate low income status if a member of household is currently enrolled in one of the following programs - CalWORKs, CalFresh, general assistance, Medi-Cal, Supplementary Security Income/State Supplementary Payment program, or California Special Supplemental Nutritional Program for Women, Infants, and Children.

Customer must provide certification from a primary care provider that discontinuation of water service will be life threatening or pose a serious threat to the health and safety of a resident.