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2. Application Type

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4. What fees are you applying to defer?

   Check all that apply

   1. Capital Facilities Fees
   2. Water Connection Fees
   3. Wastewater Capacity Fees

6. Applicant Information

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8. First Name*
9. Middle Initial*
10. Last Name*
11. Relationship to Owner*
13. Physical Street Address*
15. City*
16. State*
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
17. Zip Code*
19. Mailing Address*
21. City*
22. State*
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
23. Zip Code*
25. Phone Number*
26. Work Number*
27. Fax Number
29. Email Address*

31. Project Information

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33. Parcel Number(s)*
35. Site Address*
36. Apartment / Suite Number
38. City*
39. State*
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
40. Zip Code*
42. Name of Project*
44. Type of Project*

    Describe your project.

46. Warning: Furnishing false information on a loan application is a crime!

    U.S. Code Title 18, Section 1001 makes it unlawful for anyone to knowingly or willfully conceal a material fact, make any materially false, fictitious or fraudulent statement or make or use any false, fictitious or fraudulent writing or document. Violation of this section may be punishable by fine or imprisonment for not more than five years, or both.

48. Certify Information Provided is Accurate*

    Check the box below to certify the information provided in this application is accurate.

    1. I/We certify that the statements contained in the above schedules are true and accurate statements to the best of the applicant’s knowledge and belief.
50. Type Name to Sign*
51. Title*
52. Phone Number*
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field