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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.