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WATER QUALITY PROTECTION CHARGE HARDSHIP EXEMPTION REQUEST Application for Residential
Regulated by the Code of Montgomery County Regulations (COMCOR) § 19.35.01.08
Montgomery County Department of Environmental Protection

APPLICANT MUST ATTACH A COPY OF PROPERTY TAX BILL AND ALL SUPPORTING DOCUMENT TO PROCESS REQUEST AND SUBMIT NOT LATER THAN APRIL 1 OF THE YEAR BEFORE PAYMENT OF THE CHARGE IS DUE.

Property Tax Account No:* Name:*
Premise Address:*
Home Phone:* Cell Phone:
E-mail Address: Upload Documents:*
Maryland Energy Assistance Program
An applicant with proof of approved benefits under the Maryland Energy Assistance Program is eligible for the exemption. MEAP approval letter for the current levy year must be attached to the application.
Income Verification
Please check the household size and household income below. Current year’s tax return is required.
CheckPersons in family/householdHousehold Annual Gross Income*
1$19,839.00
2$26,741.00
3$33,643.00
4$40,545.00
5$47,447.00
6$54,349.00
7$61,251.00
8$68,153.00
For families/households with more than 8 persons add $6,902 for each additional person
*Gross income is all household income before deductions by employer for taxes, social security, etc.

By signing this application, I hereby certify that the information contained in this request and the supporting documents is true and correct. I am the owner of the above identified property. I also understand that, if approved, this exemption will apply to my account only for the current tax year.
By checking this check box, I *sign this application.
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