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2. 
3. Finance Department 200 N Castle Heights Avenue Lebanon, TN 37087
5. City of Lebanon Utility Sanitation Reduction Form

   The reduced sanitation fee of $10 will be open to our elderly (65+) and disabled customers. You must be 65 + and total income cannot exceed $38,000.It must be your primary residence. For our rental customers,  you must provide a current copy of your lease. 

9. First Name*
10. Last Name*
12. Account Number*
14. Address*
16. City*
18. Phone Number*
20. Email Address
22. Upload your ID*

    To verify your Identity, We ask you upload any form of government ID

24. Proof of Income*

    Must provide income documentation such as: Copy of last year's tax return or W-2

26. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
28. Electronic Signature*

30. I certify the income indicated is my primary source of income. I certify that I reside in or receive utility service as my primary residence for the account listed above. I understand that the reduced sanitation fee is based on my income and if any income changes, I am responsible for reporting to the City of Lebanon Finance Department. I understand at any time the City of Lebanon Finance Department can change the policy and income limit. If I move from the residence listed above, I must notify the City of Lebanon Finance Department that I received the reduced rate for sanitation.

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32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field