To be eligible for an annual late fee waiver, the household must meet one of the following: *

1. A member of the household is a current recipient of any of the following: (Check any that apply)
   

   CalWORKS	General Assistance	SSI/SSPP
   CalFresh	Medi-Cal	WIC

   
   Or*
   
   
2. The household annual income is less than 200 percent of the Federal poverty level. (See link below for the Federal poverty levels applicable in the State of California: https://www.healthforcalifornia.com/covered-california/income-limits)

Number of persons in my household

Total combined gross annual household income. $

The definition of gross household income is all money and noncash benefits, available for living expenses, from all sources, both taxable and nontaxable, before deductions, including expenses, for all people who live in my home.

I understand that completion of this form is strictly voluntary and is used solely for determining eligibility for an annual late fee waiver.

I state that the information I have provided in this declaration is true and correct. I understand that I may be requested to provide updated documentation of eligibility or participation in assistance programs at any time and agree to do so. I agree to inform the Los Angeles County Waterworks Districts if there is any change in income or eligibility for assistance programs. Declaration must be submitted annually to maintain eligibility.

By checking this box, I certify that the above answers and statements are accurate and complete. I further understand that this form must be submitted annually to maintain eligibility.