Section One: Contact Information And Message (Required)

1. Full Name

2. Account Number

3. Address of Water Service

4. Daytime Phone Number

5. Email

6. Are you the account holder?

7. Reason for contact?

8. Description of request or concern

Section Two: Application For Modified Payments (Optional)

California State Law provides several modified payment options for customers that meet all three of the qualifications below. If you believe you meet all three of these qualifications and would like to apply for modified payments, please carefully fill out this section. If you do not meet all three of the qualifications below, or if you are not applying for modified payments, please scroll down to Section Three.

Criteria 1: Life threatening situation or serious health risk.

You must provide certification that discontinuation of residential service will be life threatening to, or pose a serious threat to the health and safety of, a resident of your household. This certification must be provided by a primary care provider as defined below: Any internist, general practitioner, obstetrician-gynecologist, pediatrician, family practice physician, nonphysician medical practitioner, or any primary care clinic, rural health clinic, community clinic or hospital outpatient clinic currently enrolled in the Medi-Cal program, which agrees to provide case management to Medi-Cal beneficiaries.

Criteria 2: Financially Unable To Pay

You qualify as being financially unable to pay for residential service within the urban and community water system’s normal billing cycle if any member your household is a current recipient of CalWORKs, CalFresh, general assistance, Medi-Cal, Supplemental Security Income/State Supplementary Payment Program, or California Special Supplemental Nutrition Program for Women, Infants, and Children, or the customer declares that the household’s annual income is less than 200 percent of the federal poverty level. Please visit https://aspe.hhs.gov/poverty-guidelines for more information on federal poverty level guidelines.

Criteria 3: Willing to enter into modified payment agreement

You are willing to enter into one of the following modified payment agreements: Amortization of the unpaid balance. Participation in an alternative payment schedule. Under California state law, Rosamond Community Services District will select which of these modified payment agreements to offer and the parameters of that payment option.

Section Three: Declaration And Submission

By providing the current date and my digital signature I declare under penalty of perjury that the foregoing is true and correct.