Skip to main content

Water Shutoff Protection Request Form

MIDWAY HEIGHTS COUNTY WATER DISTRICT 16733 PLACER HILLS RD

MEADOW VISTA, CA 95722 (530) 878-8096

www.mhcwd.org

admin@mhcwd.org

Water Shutoff Protection Act

Pursuant to Section 116900 of the Health and Safety Code, Midway Heights County Water District (MHCWD) will not terminate residential service for nonpayment when specific conditions are met.

Name:

 

Account Number:

 

Owner                   Tenant

 

Service Address:

 

Email Address:

 

Mailing Address:

 

Phone:

 

City:

 

Zip:

 

All three requirements must be met to avoid disruption of water service:

1.      I can submit certification of a primary care provider, that discontinuation of residential service will be life threating to, or pose a serious threat to the health and safety of a resident of the premises where service is provided.

2.      I can demonstrate or declare that I am financially unable to pay for service within the normal billing cycle. I or a member of my household am a current recipient of (a) CalWORKs, (b) CalFresh, (c) general assistance, (d) Medi-Cal, (e) Supplemental Security Income/State Supplementary Payment Program, or (f) California Special Supplemental Nutrition Program for Women, Infants, and Children or the customer declares that the household’s income is less than 200 percent of the Federal Poverty level.

3.      I am willing to enter into a payment arrangement.

       As Condition and requirement for receiving a reduced reconnection fee from MHCWD, I hereby declare that my household income is below 200 percent of the Federal poverty line.

 

Completion of this form does not guarantee a payment arrangement. I understand by meeting the above conditions, my service may still be terminated if I fail to comply with a payment arrangement. Documentation may need to be provided upon request by MHCWD. This form is valid for 12 months from date of signature. I understand that by signing this form I agree that the information listed is true and correct. I declare that I meet the above requirements of the Water Shutoff Protection Act.

Signature:

Date: