Bonney Lake COVID-19 Residential Utility Customer Grant Assistance Program Application

Utility Account Number

Phone Number

Landlord Phone Number

To your knowledge, was your utility account in good standing as of March 1, 2020?

YES

Utility customers must be eligible for and be willing to set up a utility payment plan for any remaining balance not covered by the Residential Utility Assistance Program. Please check the box to acknowledge that you understand this requirement.

I acknowledge

Eligible residential utility customers submitting a complete and timely application will have a chance to receive a grant of up to $500 until all funds are exhausted. How much would you like to request?

Are you receiving any other water or sewer financial assistance from other government agencies? If so, describe.

Circumstances

Check all that apply and provide supporting documentation

Death of immediate family member due to COVID-19

Loss of job or income due to COVID-19

Sudden illness or injury due to COVID-19

Substantial loss of funds due to COVID-19

Severely disabled or ill household member due to COVID-19

Please provide an explanation for any areas checked.

Please upload supporting documents to the list of circumstances selected above.

Click Here to Upload

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I certify that I have provided and reviewed the information on this application. This information is accurate to the best of my knowledge. I also give my permission for the City of Bonney Lake’s Utility Assistance Program Representative to request/release necessary information that may result in my receiving benefits. I hereby authorize the City of Bonney Lake to release billing information to the City’s Utility Assistance Program Representative in order to process my application. I understand that I may or may not receive assistance under this program and if assistance is provided, the payment will be made directly to my City of Bonney Lake utility account on my behalf.