2. For full details, visit:

   https://www.co.jefferson.wa.us/1401/Septic-Cost-Share-Program

4. Applicant Name
5. Phone #
7. Date of Birth
8. Marital Status
9. Email Address
11. Mailing Address
13. Home Address
15. Co-Applicant
16. Phone #
18. Date of Birth
19. Marital Status
20. Email Address
22. Mailing Address
24. Home Address
26. Address where septic system is located
27. Parcel #
29. Has the septic system been professionally inspected?*
    -- Select One --yesno
30. *If yes, provide date
31. *if yes, provide company name
35. HOUSEHOLD SIZE DOCUMENTATION REQUIRED

    Please list each household member’s name, date of birth, and annual income. Include Applicants.

37. Full Name
38. Date of Birth
39. Annual Gross Income
41. Full Name
42. Date of Birth
43. Annual Gross Income
45. Full Name
46. Date of Birth
47. Annual Gross Income
49. Full Name
50. Date of Birth
51. Annual Gross Income
53. Full Name
54. Date of Birth
55. Annual Gross Income
57. Full Name
58. Date of Birth
59. Annual Gross Income
61. Full Name
62. Date of Birth
63. Annual Gross Income
65. Full Name
66. Date of Birth
67. Annual Gross Income

69. For individuals 18 years of age and over, please submit photocopies of the following to verify identity: 

     

    • Social Security Card

     

    And one of the following:

     

    • Photo ID
    • Medical Card
    • Birth Certificate

     

    For individuals who are under 18 years of age, please submit a photocopy of one of the following to verify identity:

     

    • Social Security Card
    • Medical, legal, tax or education document displaying full name and social security number

     

71. INCOME DOCUMENTATION REQUIRED

    
    

    1.  Two years of Tax returns for applicants must be provided.
    2. Two months of bank statements, showing income receipt.  

            AND,

    1. All household members must send proof of income in the following form:

     

    • Earned Income: Pay stubs or W4.

     

    • Unemployment Compensation:  Pay stubs or an income print-out from the unemployment office.

     

    • Social Security, VA benefits or pension:  Determination letter or bank deposits print-outs
73. Mail or drop off* household size documentation and income documentation to:

    Jefferson County Public Health
     c/o Amanda Christofferson
     615 Sheridan
    Port Townsend, WA 98368

    *Open Mon-Fri, 9 am – 4:30 pm.

75. Applicant Signature

    I/We hereby apply for the cost share described in this application. l/We certify that l/We made no misrepresentations in this application or in any related documents, that all information is true and complete, and that l/We did not omit any important information. l/We agree that any property undergoing repair will not be used for any illegal purpose. l/We understand that the Cost Share provider may retain this application and any other personal financial information Cost Share provider receives, even if no cost share is granted.  These documents will be retained under secure procedures for the appropriate retention period.

    
    

    By typing my name above, I agree to the terms listed above.

77. Co-Applicant Signature

    I/We hereby apply for the cost share described in this application. l/We certify that l/We made no misrepresentations in this application or in any related documents, that all information is true and complete, and that l/We did not omit any important information. l/We agree that any property undergoing repair will not be used for any illegal purpose. l/We understand that the Cost Share provider may retain this application and any other personal financial information Cost Share provider receives, even if no cost share is granted.  These documents will be retained under secure procedures for the appropriate retention period.

    
    

    By typing my name above, I agree to the terms listed above.

Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit

* indicates a required field