MARSHFIELD UTILITIES

INCOME VERIFICATION FORM

The information requested below is used to evaluate if your household is exempt from posting a required deposit.

INSTRUCTIONS:

Column A Print the full name of each person living in the household.
Column B Print the age of each person living in the household.
Column C Total gross income from wages for each person living in the houshold per month.
Column D Total gross income from support for each person living in the houshold per month.
Column E Total gross income from any other source for each person living in the houshold per month.

Fields with ( ) are required. If using a keyboard, press the Tab key to advance through each field.

A. Name

B. Age

C. Income: Wages

D. Income: Support

E. Income: Other

I certify that all the above information is true and correct and that ALL income is reported.

Name:

SSN (last four digits ONLY):

Phone Number:

Street:

City:

State:

Zip:

Email Address (a confirmation email will be sent to this address):

Full Name:

MU Account #:

Date:

I have read and agree to the Terms.

Verification:

Customers not wishing to complete the online application, may print the PDF version and fax, email, mail or bring to Marshfield Utilities office. Please remember processing will be delayed. Marshfield Utilities must have one business day to process a completed application, but only after it is received.

Download PDF Version