City of West Branch
121 North 4^th Street West Branch, MI 48661
(989) 345-0500
(Please print, complete & return to City Hall at the address listed above)
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Senior Citizens Water Discount

Account #: ________________________________________________________

Address: __________________________________________________________

Name: ____________________________________________________________

Senior Citizen

Affidavit for reduction of water rate for persons with 85% total income from Social Security and / or pension.

____________________________ being duly sworn, deposes and says that 85% of total income is from Social Security and / or pension.

Signed: _____________________________________

Approved: ___________________________________, Clerk