Date:
As stipulated by the Utility Board of the City of Key West, a discount has been established for residential customers who are 62 years of age or older, or who are totally or permanently disabled American Veterans,on the date of application. Such qualified applicants are required to submit this discount application for eligibility; providing that such application is prima facie evidence of eligibility; income for all qualified applicants will not exceed the amount of $32,244.00 per annum, per household, of residential single unit accounts only, for senior citizens or the maximum dollar benefit based on the United States Department of Veterans Affairs website, per annum maximum benefit, for a disabled American veteran.

All applicants must sign this application stating their legal residence, age, and annual income to qualify for this discount. All accepted applicants will be required to re-qualify from January 1 through and no later than March 31, each year for Keys Energy Services to consider a request for the residential senior citizen's discount. The following information must be provided:
 SENIOR CITIZENS:
Account Holders Name:
Address:
Date of Birth:     Age:     Phone:     E-mail:
KEYS Account Number:     Annual Income: $
 PERMANENTLY DISABLED AMERICAN VETERANS:
Account Holders Name:
Address:
Date of Birth:     Age:     Phone:     E-mail:
KEYS Account Number:
Percentage of Disability: %
Number of children:     Spouse:
Do parents live with you?:     If yes, how many:
Monthly Income:$
I swear or affirm that the foregoing statements are true to the best of my knowledge and belief. I grant KEYS the authority to verify my statements. Falsely stating income will result in back billing and all associated fees, if KEYS obtains information which indicates income exceeds qualification levels as established by the aforementioned agencies. I certify that the address given is my legal residence and are where my domestic duties are comprised. It is hereby understood by the applicant that any false statement will provide sufficient reason to void this application.
I ACCEPT - I understand that by checking the box next to the words "I ACCEPT" and typing my name below, I am signing this document electronically.

Signature of Applicant:

Application Accepted By KEYS Rep:
Form last revised: 04/10/15