INSTRUCTIONS FOR SENIOR CITIZEN AND DISABLED PERSONS RATE REDUCTION APPLICATION
Must Be Submitted Annually

PART A

• List the address at which you own and reside. The income of all persons listed on the deed of the property will be considered.
• List the Block number of the property.
• List the Lot number of the property.
• List the apartment number of your residence if applicable.
• List the Town (Freehold, Manalapan, Marlboro) in which your property is located.
• List your mailing address if different from the property address.
• List your phone number.

PART B- Each owner listed on the deed of the property must complete items 8 through 13.

• Provide your name, last name first and first name last.
• Enter your date of birth. Applicants must be 65 years of age by the date of the application or be permanently and totally disabled pursuant to the federal Social Security Act (42 U.S.C Section 301 et seq.) disabled under any deferral law administered by the US Department of Veteran Affairs, if the disability is rated 60% or higher.
• Enter your Social Security Number.
• Enter your PAAD Card number. It is not mandatory to possess a PAAD Card. If you do not have this card, you must enter an amount at Item #13- Total Income.
• If applying for the reduction due to a disability, submit proof of the disability by submitting a copy of one of the following documents:
  • Social Security Award Certification (SSA-L30) issues by the Social Security Administration within the last 6 months or
  • Verification of your disability status by your local Social Security Office through “Report of Confidential Social Security Beneficiary Information” (SSA-2458) or Third Party Query Form which indicates your current Social Security Disability status.
• This item is only be completed by persons not possessing a PAAD Card. All owner/occupants must have a combined income which does not exceed $10,000 (SEE INCOME WORKSHEET) excluding any benefits received under one of the following:
  • Federal Social Security Act;
  • Any other program implemented by the federal government pursuant to federal law which provides benefits in part or in whole in lieu of Social Security benefits, such as federal pension, retirement or disability programs and the federal Railroad Retirement Act of 1974;
  • Pension retirement or disability programs of any state or political subdivision or its agencies for individuals not covered under the Social Security Act.

PART C- All owners must certify that the information contained in the application is true and all Owners reside at the address listed. Owners applying as PAAD Card holders need not submit Proof of Disability or Income Tax Returns.

PART D- Once the application is reviewed by the Executive Director, he will enter comments or a request for further information in this area and approve or deny the application.

BILLING INFORMATION- If the application is approved, the Billing Clerk will enter the date on which you will receive the first quarterly reduction. The reduction will apply to the first full quarter after which the application has been approved. Partial quarters will not be pro-rated.

APPLICATION FOR SENIOR CITIZEN AND DISABLED PERSONS RATE REDUCTION

Western Monmouth Utilities Authority
103 Pension Road,
Manalapan, NJ 07726
(732) 446-9300

Must be submitted annually WMUA Account Number:

PART A – PROPERTY LOCATION (applicants MUST be owners and reside at this location)
Street Address	Block	Lot	Unit No.	Town
Mailing Address			Phone Number

PART B – OWNER INFROMATION (provide information for each owner)
Owner #1- Last Name	First Name	Date of Birth
Social Security No.		PAAD Card No.
If you are disables and do not hold a PAAD card, submit proof of disability.
Prior Year Income – Complete only if you do not hold a valid PAAD Card. (SEE INCOME WORKSHEET BELOW)		Total Income $

Owner #2- Last Name	First Name	Date of Birth
Social Security No.		PAAD Card No.
If you are disables and do not hold a PAAD card, submit proof of disability.
Prior Year Income – Complete only if you do not hold a valid PAAD Card. (SEE INCOME WORKSHEET BELOW)		Total Income $

Owner #3- Last Name	First Name	Date of Birth
Social Security No.		PAAD Card No.
If you are disables and do not hold a PAAD card, submit proof of disability.
Prior Year Income – Complete only if you do not hold a valid PAAD Card. (SEE INCOME WORKSHEET BELOW)		Total Income $

INCOME WORKSHEET
Do Not include Social Security Benefits

INCOME YEAR:	Salary/Wages	Pension Benefits	Interest & Dividends	Other Income	Total Income
OWNER #1
OWNER #3
OWNER #3

APPLICATION FOR SENIOR CITIZEN AND DISABLED PERSONS RATE REDUCTION

Western Monmouth Utilities Authority
103 Pension Road,
Manalapan, NJ 07726
(732) 446-9300

Must be submitted annually WMUA Account Number:

PART C – OWNER CERTIFCIATIONS (must be signed by all persons listed in PART B)
I hereby certify that the information provided above is accurate and true and that I am both an owner and resident at the location listed in Part A.
Owner #1	Date
Owner #2	Date
Owner #3	Date
For Each Owner Please Submit as Applicable: Copy of PAAD Card Copy of Deed Proof of Disability Copy of the previous year State and Federal Income Tax Return

Submit