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Application For Senior Citizen Sewer Service Charge Exemption Form - City Of Chicago Department Of Finance

City of Chicago Department of Finance

Utility Billing & Customer Service

P.O. Box 6330

Chicago, IL 60680-6330

Application for Senior Citizen Sewer Service Charge Exemption

*Account Number: _____________ - _____________

*Service Address: ______________________________________________________________

*Owner Name: ________________________________________________________________

(as currently listed on bill)

Last

First

*Phone Number: ___________________ Email Address: _____________________________

*Owner Birth date: ____________________________

* Property Index Number: _____-_____-________-________-______________

(Found on Property Tax Bill)

To be eligible for the sewer service charge exemption you must meet the following criteria:



You must be 65 years of age or older on the day you apply



Occupy the property as your principal place of residence



Residence must be a single family home or a unit with its own, separate water account

You must provide the following documentation with your application:

1. Proof of age – copy of the applicant’s State ID or Federal ID, showing Date of Birth

(State ID, driver’s license, passport, birth certificate, matrícula consular)

2. Proof of ownership – copy of deed or property tax bill in the applicant’s name

†

3. Proof of residency – copy of water bill or tax bill for the property in the applicant’s name

The undersigned on oath deposes and says that he/she is the owner of said real property, said property is a

single family dwelling or has a separate metered water service or water assessment for a residence that is not a

single family home, that this is his/her principal place of residence, is 65 years of age or older and otherwise

qualifies for exemption under Section 3-12-050 of the Municipal Code of the City of Chicago, and that he/she

is subject to penalties for perjury for falsification herein.

Print Name: _____________________________________________________________

Signature: _________________________________ Date: ________________________

*Required Field

Approved

Disapproved

By: _________________________________

For properties held in trust, a Trust Agreement or

†

Date: _______________________________

Disclosure of Beneficiaries is required in addition to

the deed or tax bill

Reason: _____________________________

Application For Senior Citizen Sewer Service Charge Exemption Form - City Of Chicago Department Of Finance

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