Thank you!

We will get to your request as quickly as possible. Once your request has been submitted and processed, you will receive confirmation within a week.

If you have questions concerning additional resources, contact one of our client advocates:

Email: [email protected]
Phone: (727) 823-3471 ext. 101

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There was an error with your request. Please contact support.

Water Assistance Application

First and last name *

Street Address (physical location) *

City *

Zip code *

Name of your current water company *

Account number *

Name on water bill (if not yours, please add relationship - example: landlord) *

Date of birth *

Last 4 digits of your social security number *

Phone number *

Email address

Ethnicity

African American

Asian

Caucasian

Hispanic

Middle Eastern

Native American

Pacific Islander

Other

Are you a veteran? *

Yes

Are you receiving SNAP benefits? *

Yes

If you answered "No" to receiving SNAP Benefits, please choose from below as to why... *

I do receive SNAP.

I am not eligible for SNAP.

I will apply or have applied.

I am not interested in applying.

Not provided.

How many children in the household aged 0-3 (if none put 0) *

How many children in the household aged 4-17 (if none put 0) *

How many adults in the household aged 18-54 (if none put 0) *

How many seniors in the household aged 55+ (if none put 0) *

Are you behind on your rent, mortgage, or electric?

Yes

Click the button below to upload a copy of your current water bill *

Click the button below to upload a copy of your drivers license or ID *

Signature *