WIN Application

WIN, or the Water Incentive Program, is a program from the City of Salisbury. Eligible households may receive one payment per year in an amount up to $2,000 towards their water and/or sewer bills.

Eligibility Information
Applicants must be Maryland residents who are responsible for the payment of a water and/or wastewater bill issued by the City of Salisbury, MD. Applicants must live at the property for which assistance is being provided. Total household income may not exceed the gross income thresholds shown below. Applicants are considered automatically eligible for the WIN Program if they are currently receiving any of the following assistance: • Energy assistance from the Office of Home Energy Programs (OHEP) • Temporary Cash Assistance (TCA) • Temporary Disability Assistance Program (TDAP) • Supplemental Nutrition Assistance Program (SNAP) • Supplemental Security Income (SSI) • Emergency Rental Assistance Program (ERAP)
BEFORE YOU BEGIN:
You will be asked to provide supporting documentation in this application. Be sure to fill out the application clearly and completely. You must provide documentation to prove any information provided on this application. Documentation includes a copy of a Driver's license or other government-issued identification card, proof of where you live (this can be your water and/or wastewater bill), copies of Social Security cards for everyone in your household, and proof of all gross (pre-tax) income for everyone in your household for the last 30 days (such as a paystub, Social Security letter, child support letter, unemployment letter, self-employment documentation, etc.). If your household received no income in the 30 days prior to this application, you must sign a Declaration of Zero Income and provide additional information on how your household is meeting your basic needs. The form is available on the Home Energy website https://dhs.maryland.gov/office-of-home-energy-programs/.
What language do you speak?*
- English
- Spanish
- Haitian Creole
Applicant Information
Name*
9-Digit Social Security Number*
Email Address*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone Number*
Secondary Phone Number*
Water/Sewer Information
Company Name*
Account Number*
Name on Account*
Service Address*
Street Address Address Line 2 City State ZIP Code
I have a termination notice*
- Yes
- No
My water service has been disconnected*
- Yes
- No
Water balance past due:
My household rents our home and the water bill is in the landlord's name.*
- Yes
- No
If yes, please provide your landlord's name or company, street address, and phone number.
If yes, please provide a copy of your most recent rental receipt or lease stating that water is covered in your rental fee.
Accepted file types: jpg, png, pdf, Max. file size: 256 MB.
Household Information
If the applicant or any household members aged 18 or older received income in the 30 days prior to the submission of this application, you will be required to provide proof (paystubs, benefit award letters, etc.) of all income received. Providing proof at the time of application will help expedite the processing of your application. For each household member in the table below, list all sources of income received in the last 30 days. Please fill in all information for each applicable household member.
First and Last Name
Date of Birth
U.S. Citizen?
- Yes
- No
9-Digit Social Security Number
Relationship to Applicant
30-Day Gross Income (pre-tax)
Income Sources (Wages, TCA, SSI, SSDI)
Other Assistance Received
If you answer YES to any of the questions below, please help expedite the processing of this application by attaching a copy of the award letter or other proof of assistance received.
Do you receive energy assistance through the Office of Home Energy Programs (Maryland Energy Assistance Program, Electric Universal Service Program)?*
- Yes
- No
Do you receive Supplemental Social Security?*
- Yes
- No
Do you receive Veterans of Social Security Disability Benefits?*
- Yes
- No
Do you receive any other form of financial assistance from the State of Maryland (SNAP, TCA, TDAP, ERAP)?*
- Yes
- No
if yes, please identify the assistance rerceived.
Please attach relevant award letters or other proof of assistance received here.
Drop files here or

Max. file size: 256 MB.
Acknowledgement and Signature
You or your Authorized Representative must sign this application before submitting it. I swear or affirm under penalty of perjury that all the information I gave to the Department of Human Services in this WIN Application is true, correct, and complete to the best of my ability, belief, and knowledge. I am a Maryland resident who is responsible for payment of a water and/or wastewater bill issued by a public water system or treatment works. . I live at the property for which assistance is being sought. I authorize DHS and/or the Office of Inspector General (OIG) to investigate and confirm the accuracy and completeness of all household income and other information provided with this application, including but not limited to the use of governmental and consumer reporting agency data regarding employment income. I consent to allow my water and/or wastewater service provider to provide relevant account information to DHS and for DHS to communicate with those providers regarding this application. I allow DHS to release and exchange relevant information with other agencies and my water and/or wastewater service provider in order to make appropriate referrals to services that may assist me to lower my water bill or help me to better afford my water and/or wastewater costs or help me with the completion of my application. I consent for my information to be entered into other secure databases for tracking of services, statistical information, and program evaluation. Maryland has a fraud law that will be vigorously enforced for intentional misrepresentations of information contained on this application. Punishment can occur for not telling the truth when applying for assistance. I understand that, if I intentionally misrepresent information, I may be disqualified from the program for a set amount of time.
Date*
MM slash DD slash YYYY
Full Name of Applicant*

e-Signature
Comments
This field is for validation purposes and should be left unchanged.

WIN Application

Eligibility Information

BEFORE YOU BEGIN:

Applicant Information

Water/Sewer Information

Household Information

Other Assistance Received

Acknowledgement and Signature