Auburn, WA · King County
Affidavit for Claim of Disability
This affidavit is for first-time applicants seeking a City of Auburn utility rate exemption based on permanent disability.
What this form is
First-time applicants use this affidavit to claim a City of Auburn utility rate exemption based on permanent disability. The applicant certifies that they meet the disability criteria stated on the form. A physician’s office completes its section, and verification is required as either an office stamp or a letter on office letterhead.
Who needs it
First-time applicants seeking a utility rate exemption based on permanent disability need this affidavit and physician’s office verification.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed without a notary; the applicant certifies the claim under penalties of perjury, and the physician signs and dates the form.
How to submit this form
- 1
Download The Affidavit
Download the Affidavit for Claim of Disability PDF.
- 2
Complete The Applicant Information
Fill in the applicant information and certify that the stated disability criteria are met.
- 3
Get Physician Verification
Have the physician’s office complete its section and provide an office stamp or a letter on office letterhead.
- 4
Submit The Affidavit
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- Do I need a notary for the Affidavit for Claim of Disability?
- No. This document is signed without a notary. The applicant certifies the claim under penalties of perjury, and the physician signs and dates the form.
- Who uses this affidavit?
- First-time applicants seeking a City of Auburn utility rate exemption based on permanent disability use this affidavit.
- What verification is required?
- The form requires verification from the physician’s office: either an office stamp or a letter on office letterhead.
- How do I submit the affidavit?
- Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Affidavit for Claim of Disability doesn’t need a notary — but if you have another Auburn form that does, a commissioned online notary can help.