DeKalb County Water Grant Conference Request

The DeKalb County Water Grant was awarded to SVdP Georgia to assist our clients with their water bills in DeKalb County. This is a reimbursement grant and you are required to submit appropriate documentation to show that the client meets the grant criteria. The reimbursement will be for assistance provided from November 17, 2021 to December 31, 2023, or until funds are exhausted.

Here is the information for the income limits:

# in household Maximum income
1 $48,300
2 $55,200
3 $61,100
4 $68,950
5 $74,500
6 $80,000
7 $85,500
8 $91,050

PLEASE SUBMIT THE FOLLOWING FORM FOR REIMBURSEMENT:

"*" indicates required fields

Conference/Caseworker Information

Name of Person Submitting Request*

First Last

Email*

District*

Conference*

CMS Case #*

Client Information

Client Name*

First Last

Address*

Street Address Address Line 2 City ZIP Code

Amount paid*

Date Assistance Was Provided*

Upload Copy of Bill*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Accepted file formats: jpg, gif, png, pdf

PLEASE CHECK THIS BOX TO CONFIRM THAT CLIENT LIVES IN DEKALB COUNTY*

I CONFIRM THAT THIS CLIENT LIVES IN DEKALB COUNTY.

PLEASE CHECK THIS BOX TO CONFIRM THAT THIS CLIENT MEETS THE INCOME LIMITS*

I CONFIRM THAT THIS CLIENT MEETS THE MAXIMUM INCOME LIMITS AS NOTED ABOVE.

PLEASE CHECK THE APPROPRIATE BOX TO CONFIRM THAT THIS CLIENT HAS A COVID-19 IMPACT*

UNEMPLOYMENT INSURANCE

POSITIVE COVID-19 TEST FOR CLIENT OR FAMILY MEMBER

REDUCED WORK HOURS AS DEMONSTRATED BY PAY STUBS

OTHER OR SELF-ATTESTATION

UPLOAD COPY OF COVID-19 IMPACT*