Lakehaven Assistance Application

Woman holding young child smiling outside

Name(Required)

First Last

Date of Birth(Required)

Please provide your date of birth. Please include month, date, and year.

Social Security Number(Required)

Please provide the last four digits of your social security number.

Household Size(Required)

Please provide the number of people living in your household. Include all occupants regardless of age.

Household Income(Required)

Please provide the total of all household income received during the one full month prior to the month you are submitting your application. For example, if you are submitting your application in June, please include all income for the month of May only. This must include income for any occupant of your household age 18 years or older at the time of your application.

Lakehaven Utility Account Number(Required)

Please provide your utility account number for Lakehaven.

Do you have a current and valid shut-off notice from Lakehaven Water & Sewer District(Required)

Yes

Shut-off date (if available)

Address(Required)

Address must be your current address.

Street Address City State ZIP / Postal Code

Phone(Required)

Email(Required)

Acceptance Conditions and Disclaimer(Required)

I acknowledge that I am requesting assistance with my Lakehaven utility bill and the following conditions apply for my acceptance:

• The maximum benefit I may be eligible for is $100 one time per calendar year.
• The eligibility requirements are based on my reported household size and household monthly income.
• Depending on the fund availability, I may or may not be able to receive the assistance.
• Additionally, I acknowledge MSC is only processing one-time $100 assistance on my Lakehaven bill. MSC is not responsible for the remaining balance for my Lakehaven bill.

I have read, understand, and agree to the conditions and disclaimer.

Document Upload(Required)

Please upload the required documents listed above. If you do not have a scanner, you make take photos with your phone. Please make sure all information is legible.

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Notice: This form is not for transmitting personal health information. Please do not include details about your medical history or condition. For confidential matters, contact us by phone.