This form is for households with 4 or more persons only. Date: Phone: Name: NDC Acct #: Email: Address: By signing/submitting this form, the applicant certifies the above information and acknowledges that: I am applying or reapplying for an annual increased water budget because the above address is the primary residence for persons. The granting of an increase in Water Budget for this purpose is subject to annual renewal. The information contained in this form is subject to audit. Should an audit be necessary, applicant agrees to provide acceptable documentation of the actual household population. Such documentation may include, but is not limited to: copies of Federal 1040 tax forms, driver's licenses, or other records which show proof of residence. If any of the information supplied on this application by the applicant is found to be false, the fees and charges will be adjusted retroactively to the date of this application and appropriate fees and charges added to the next utility services bill for the address. Applicant understands that water usage in excess of the assigned water budget may result in significantly higher costs as an incentive to use water wisely. <-- Pressing send is your electronic signature. If you would rather mail, please print out this form and send in with your signature at the bottom to: Northern Douglas County Water and Sanitation District 8390 E. Crescent Parkway, Suite 300 Greenwood Village, CO 80111 303-265-7949 Return fax no. 303-773-2050
