First Name     Last Name      Middle Initial
Service Address    City  Zip Code
LWC/MSD Account Number    Phone Number (999) 999-9999  
Number of Household Members   Current Total Monthly Income
Email Address  Confirm Email Address

*Total household income defined as the combined taxable and non-taxable income of ALL persons living at the address, including:

Wages or salaries, Pensions, Gross income from self-employment (IRS Form 1040 Schedule C), Child or spousal support, Worker’s compensation, Unemployment benefits, Disability payments of SSDI, Social Security, SSI/SSP, Rent or royalty income, Insurance or legal settlements, Interest or dividends from savings accounts, stocks, bonds, or retirement accounts, Proceeds-sales price (IRS Form 1040 Schedule D), Cash income or gifts.


Household members
Name 1 Age Name 2 Age
Name 3 Age Name 4 Age
Name 5 Age Name 6 Age
Name 7 Age Name 8 Age
Name 9 Age Name 10 Age


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Customer Signature   Date