Thank you for applying to the Department of Watershed Management Care and Conserve Program. The Care & Conserve water bill assistance program helps residential water customers who pay their water bills to the City of Atlanta Department of Watershed Management.

If your application is approved,assistance can only be granted once within a two (2) year period. Determination of eligibility is determined primarily by income.

Eligibility

• The account must have gone through six (6) billing cycles to receive assistance.

• The account must have a past due amount of $300 or more at the time of application. We cannot assist with deposits for new accounts or assist with funds to turn water service on.

• The customer must currently live on the property for which you are requesting assistance and the water service must legally be on.

• The account must have a consistent demonstration of payments. An inconsistent payment history may result in a denial of assistance. A broken payment arrangement may result in a denial of assistance.

• An established payment pattern or payment arrangements may be required for a portion of the past due bills in order to receive assistance. Arrangement amounts are based upon bill balances and payment history.

• Water bill accounts and the application will be reviewed in order to determine eligibility. Applicants will be notified of their application status by phone or by mail. It can take four (4) weeks or more to process an application.

• You are responsible for making payments on your water bill during the application process.

• All requested documentation must be provided in order to process the application. The Department of Watershed Management reserves the right to require the provision of additional documents not listed above if additional verification is required.

Water bill accounts, supporting documentation and the application will be reviewed in order to determine eligibility.

PLEASE ALLOW AT LEAST 4 WEEKS TO BE NOTIFIED OF APPROVAL STATUS

The Care and Conserve Bill Payment Assistance Application has five (5) sections.
Complete all sections prior to clicking submit.

SECTION 1: CUSTOMER INFORMATION

DUPLICATE SUBMITTALS MAY RESULT IN A DELAY IN THE APPLICATION PROCESS

Customers who apply for Care and Conserve Bill payment assistance through the online process should not submit any other version of the application.

Customers who have previously submitted an application by U.S. mail, fax or email, should contact Care & Conserve by phone at(404)546-3620 or email careconserve@atlantaga.gov for updates and general questions.

Account Number (Only use numbers in the Account #. Example 003-0003-300) *

Home Address *

City, State and Zip Code *

Mobile Phone

Home Phone

Email Address *

Choose one of the following: *

Renter’s MUST complete the below information in order to receive assistance*

Landlord’s Name *

Landlord’s Phone Number *

Landlord's Email Address

Landlord's Mailing Address *

Landlord’s City, State Zip *

Are you receiving rental assistance from the housing authority for your home? *

Yes

SECTION 2: HOUSEHOLD POPULATION

Everyone Matters. List the information for EVERY person that lives in your household at the time of application.

Type in their first and last name, birthdate, last 4 digits of their Social Security Number and the dollar amount of their monthly income.

Customer (Person 1)

Customer First Name *

Customer Last Name *

Customer Date of Birth (MM-DD-YYYY) * +

Last 4 digits of Social Security Number *

Monthly Income ($) *

Person 2

Please Select One

Person 2 First Name

Person 2 Last Name

Person 2 Date of Birth (MM-DD-YYYY) +

Last 4 digits of Social Security Number

Person 2 Monthly Income ($)

Person 3

Please Select One

Person 3 First Name

Person 3 Last Name

Person 3 Date of Birth (MM-DD-YYYY) +

Last 4 digits of Social Security Number

Person 3 Monthly Income ($)

Person 4

Please Select One

Person 4 First Name

Person 4 Last Name

Person 4 Date of Birth (MM-DD-YYYY) +

Last 4 digits of Social Security Number

Person 4 Monthly Income ($)

Person 5

Please Select One

Person 5 First Name

Person 5 Last Name

Person 5 Date of Birth (MM-DD-YYYY) +

Last 4 digits of Social Security Number

Person 5 Monthly Income ($)

Person 6

Please Select One

Person 6 First Name

Person 6 Last Name

Person 6 Date of Birth (MM-DD-YYYY) +

Last 4 digits of Social Security Number

Person 6 Monthly Income ($)

Person 7

Please Select One

Person 7 First Name

Person 7 Last Name

Person 7 Date of Birth (MM-DD-YYYY) +

Last 4 digits of Social Security Number

Person 7 Monthly Income ($)

Person 8

Please Select One

Person 8 First Name

Person 8 Last Name

Person 8 Date of Birth (MM-DD-YYYY) +

Last 4 digits of Social Security Number

Person 8 Monthly Income ($)

Person 9

Please Select One

Person 9 First Name

Person 9 Date of Birth (MM-DD-YYYY) +

Last 4 digits of Social Security Number

Person 9 Monthly Income ($)

Person 10

Please Select One

Person 10 First Name

Person 10 Date of Birth (MM-DD-YYYY) +

Last 4 digits of Social Security Number

Person 10 Monthly Income ($)

SECTION 3: HOUSEHOLD INCOME

Please list the total monthly dollar amount for every type of income received in the household next to the section for that income type.

Be prepared to provide supporting documentation for any income listed.

Wages

Pension or VA benefits

Self-Employment

Social Security Benefits or Railroad Retirement

Unemployment Insurance

Supplemental Security Income (SSI)

Temporary Assistance For Needy Families (TANF)

Disability

Housing Authority Utility Assistance

Do you have other income? *

Other Income (specify)

Give a brief description of the source of income

Other Income (specify)

Give a brief description of the source of income

Total monthly Income of Entire Household:

0.00

Do you need to see a scrollable list of the supporting documents you may need?

BILL PAYMENT ASSISTANCE SUPPORTING DOCUMENTS

A submission of verification documents is required for your bill payment assistance application to be considered for approval.

Legal Guardian and Power of Attorney

If you have authority and fiduciary responsibilities over the water bill account for a customer, you must submit a copy of your power of attorney or legal guardian document.

Proof of Income

Working Persons

- Last 3 paycheck stubs from all employers

- Social Security Benefit (SSB) award letter

Self-Employed Persons

- Form 1099 forms

- Tax filings

- Records of payment for services or goods

Unemployed Persons

- A copy of your unemployment insurance benefit award letter

Retired Persons

- Supplemental Security Income (SSI) award letter

- Social Security Benefit (SSB) award letter

- Disability award letter

- Pension statement

- Retirement statement

Other Income Documents

- Temporary Assistance for Needy Family (TANF) statements

- Veterans Assistance Benefit statements

- Any other financial assistance documents including utility vouchers

- Atlanta Housing Authority Certification Letter

- Social Security Benefit (SSB) and disability award letters (Dependents)

Documents for School Aged Children

Atlanta Public Schools and Fulton County Public Schools (Including Charter)

- Student Summary Report

Homeschool (before March 15, 2020)

- Georgia Department of Education Declaration of Intent with a 36-character parent signature

Private School

- A letter of registration from the school verifying the child’s home address of record for the school year.

Do not submit supporting documents for your household until after your
application has been deemed eligible by a Care & Conserve representative.

SECTION 4: TERMS AND CONDITIONS

I have declared all members of my household presently residing in my place of residence and have provided all sources and amounts of income for all persons living in my household to the City of Atlanta Department of Watershed Management for the purpose of receiving Care & Conserve Water Bill Payment Assistance.

I understand that if any or all of the information that I have provided in this Application is found to be invalid or falsified, that all customers associated with the account can and will be required to repay the City of Atlanta for all goods, services and assistance rendered to the customer's account under the Care and Conserve Program.

I also understand that any person who knowingly and willfully falsifies, conceals, or covers up a material fact, or makes a false, fictitious or fraudulent statement may have all assistance revoked and is subject to punishment, fine and imprisonment by federal and state agencies. I also represent that I am authorized to apply for all persons who own or are authorized to access any of my accounts and that such persons will be bound by the terms of this application.

I understand that I must provide the verification documentation in order to receive Care & Conserve Water Bill Payment Assistance and that Athe City of Atlanta Department of Watershed Management reserves the right to require the provision of additional documents not listed above if additional verification is required. By selecting the “I Agree” button below, I also understand that I am legally bound to the Terms and Conditions of this Application.

I have read and agree to the Terms and Conditions above *

I AGREE

SECTION 5: ELECTRONIC SIGNATURE

I declare to the best of my knowledge the above information contained in the application is true and this is an accurate statement.

By signing this Electronic Signature Acknowledgment Form, pursuant to the Georgia Uniform Electronic Transactions Act (O.C.G.A. § 10-12-1 et seq.) as amended from time to time, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding. I also represent that I am authorized to apply for all persons who own or are authorized to access any of my accounts and that such persons will be bound by the terms of this application.

Signature of Customer or Person Legally Authorized to Act on Behalf of the Customer* (Please Type The Name) *

If the customer listed above is unable to sign on their own behalf and you are the legal guardian or power of attorney representative signing on behalf of the customer, please sign above and complete the following below.

Your Name

Relationship to Customer

Address of Person Signing (if different from Customer)

Do Not Use The Fields Below

SECTION 6: DWM OFFICE PURPOSES ONLY

Eligibility Level:

Eligible: [ ] Yes No [ ]

[ ] Approved / Manager Approval/ Signature:

Reviewer:

Date:

[ ] Denied / Reason for Denial: