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2. Applicant First Name:*
3. Applicant Last Name:*
5. Co-Applicant First Name:
6. Co-Applicant Last Name:
8. Street Address of Your Well:*
10. Property Owner Name (if different from above):
12. Email Address:
14. Mailing Address:*
15. City:*
17. State*
18. Zip Code:*
20. Phone Number:*
22. Did your well start experiencing issues after March 31, 2021 (to present)?*

    1. Yes
    2. No
24. Did someone from the Klamath Watermaster’s Office check your well? *

    1. Yes
    2. No
26. Did you report your dry or impaired domestic well online using the Dry Well Reporting form?*

    1. Yes
    2. No

    This form is available on the "Information on Failing Residential Water Well" page on the Klamath County website.

28. Income

30. Check the box that best describes your annual household income:*

    Applicants will not be turned away based on income and may be eligible for further assistance through other State grant programs.

    1. below $25,000
    2. $25,001 - $50,000
    3. $50,001 - $75,000
    4. $75,001 - $100,000
    5. above $100,000
32. Financial Impact
34. Did you incur financial cost to address your well issues? *

    1. Yes
    2. No
36. Do you have receipts or invoices?*

    1. Yes
    2. No
38. What is the amount of financial assistance you are applying for (enter dollar amount up to the maximum grant of $40,000):*
40. Were you not able to seek well repairs due to financial hardship? *

    1. Yes
    2. No
42. Have you scheduled any appointments with well professionals to inspect your well?*

    1. Yes
    2. No
44. When are the appointments scheduled and what contractor(s) are you working with?
46. Please provide a brief explanation of when you started noticing issues with your well and what the issues were or are; dates required:*
48. Is your well functioning properly now?*

    1. Yes
    2. No
50. Provide any additional information you would like the review committee to know about your well:*
52. Do you consent to having OWRD or a 3rd party contractor inspect your domestic well?

    1. Yes
    2. No
54. What type of property are you applying for?*

    1. Primary Residence
    2. Rental Home
    3. Secondary Home

56. Costs Paid for by Others: Recipient may not use any of the Grant to cover costs to be paid for by another State of Oregon agency or any third party.

    **A pre-check of your domestic well is a requirement for approval of grant funding.  A final inspection is required for release of grant funds.

    By signing below you consent Oregon Water Resource Department to inspect your Domestic Well.

58. Document Upload*

    Upload a completed IRS W-9 form and include any other documents (maps, receipts, estimates for repair etc.) that will assist the review committee with the processing of your application.

    Document upload is REQUIRED before submission. 

    ALL DOCUMENTS MUST BE COMBINED INTO ONE PDF FILE AND THEN UPLOADED.

    
    

60. Applicant Electronic Signature Agreement*

    I affirm that the information provided above is accurate and true.

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree
62. Applicant Electronic Signature*
64. Co-Applicant Electronic Signature Agreement

    I affirm that the information provided above is accurate and true.

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
66. Co-Applicant Electronic Signature
Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit Submit and Print

* indicates a required field