Lead Service Line Request Application Form

Lead Water Service Line Replacement Application

The following documents must be submitted with the application to be considered by DC Water or the District Department of Energy and Environment (DOEE) for the benefits or services requested:

Required:
- Your Government-Issued Photo ID
- Proof of property ownership
- Proof of Owner Authorization
  (If you are not property owner)
- Account Number
Optional:
- Repair Cost Quote
  (If you are applying for the Lead Pipe Replacement Assistance Program and have one from your contractor)

Which Program Are You Applying For?

Check our application guide if you need help selecting a program.

Program Name

Note: Only Lead and Galvanized Pipes are eligible.

House by House Priority Full Lead Water Service Replacement Assistance Program (HBH Priority Replacement)

Why Do You Qualify

The property is occupied by pregnant/nursing women.

The property is occupied by children under 6.

The property is occupied by person with elevated blood lead levels.

The property is a child development facility.

The property has a lead water level which exceeds the EPA lead action level (15ppb).

(You can request a free annual water test kit at dcwater.com/lead).

Do You Own This Property

Owner Authorization

An authorized representative of the property owner(s) may apply on behalf of the property owner(s) if the representative provides.

A written document signed by the property owner designating the authorized representative to act on their behalf of the property owner(s); or
Other documentation that affirms the authorized representative is authorized to act on behalf of the property owner(s).

Does the Owner Live Here?

First Name

Last Name

Service Address

Is this a commercial building, or an apartment, condominium, duplex, or other multi-family building

Apartment Unit Count

Mailing Address ( If different than service address )

Best Phone Number

Other Phone Number

Email Address

Preferred Language

Upload Your Proof Of Ownership

Your Valid Photo ID

Please attach a picture or scan of a government-issued photo ID, like a license or passport.

Proof You Own Home

Acceptable proofs of ownership include: a deed, mortgage, settlement agreement, DC property tax bill, tax assessment, home insurance policy, or home line of equity statement. To find a copy of your DC property tax bill online:

Go to mytax.dc.gov
Find the 'Real Property' section
Click on 'Search Property'
Enter your address
Go to the 'Tax Information' section
Go to the 'Billing History' section
Here you can download your most recent DC property tax bill

DC Water Account Number

Repair Cost Quote (If you are applying for LPRAP)

By Signing I hereby:

Affirm that all information in this application is true and complete to the best of my knowledge.
Understand that I can be penalized by fine and/or imprisonment for making false statements.
Understand that my signature on this application grants DC Water and DOEE permission to contact any parties necessary to verify the information that I have provided.
Understand that I am obligated to pay my DC Water bills regardless of approval or disapproval of this application.
Authorize DC Water to provide my DC Water account information to District agencies and DC Water contractors from whom I may seek assistance, and for purposes of verification, research, evaluation, and analysis.
Grant DC Water and DOEE permission to provide me with information about other programs from which I may also be eligible.
Understand this assistance is a one-time benefit per eligible District property, subject to the availability of funds.
Understand that LPRAP work must be completed within ninety (90) days of receiving a benefit determination or I may have to reapply.

Your Signature

Signature Date

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