COVID-19 UTILITY RELIEF PROGRAM Utility Arrearage Assistance |

Date (required)

Account Number (required)

Amount Due on Current Bill (required)

Address (required)

Address Line 1

Address Line 2

City

State

Zip Code

Phone (required)

Customer Type

RESIDENTIAL CUSTOMERS – COMPLETE THIS SECTION

Name of Residential Account Holder (required)

First

Last

For residential customers, place a mark beside applicable cause of economic hardship if you or a person in your household has experienced a loss of income due to the COVID-19 pandemic. Check all that apply. (required)

(describe)

COMMERCIAL CUSTOMERS – COMPLETE THIS SECTION

1. Name of Non-Residential Account Holder (required)

First

Last

Property Name

Is the utility fee arrearage due to economic hardship experienced by the customer as a result of the COVID-19 pandemic? (Check Y/N) (required)

YES (Eligible for relief; provide explanation below)
NO (Not eligible for relief)

4. Provide and explanation of the COVID-19 related economic hardship: (required)

This CARES Act Assistance Application:

* Will provide assistance for bills dated March 1, 2020 to December 30, 2020, and may not be used for past due amounts prior to this time period.
* Is designed to be a one-time opportunity, with only one payment per household (for residential) or account holder and their successors (for commercial).
* May only be used to pay wastewater charges. It will not be applied to refuse or storm water charges. These amounts are still due.

Applicant’s Certification:

* I desire to receive any assistance to which I am legally entitled under this program and its specifications.
* I certify that the reason I am eligible for this CARES Act assistance is correct to the best of my knowledge and belief.
* I understand that my signature on this form gives permission for the City of Hopewell (Hopewell Water Renewal) to verify records as necessary to verify my eligibility for assistance.
* I certify that this account/customer has not received CARES act relief for any of the arrearages I am applying for from any other source including Rebuild VA Grants.
* I understand that if I give false information or withhold information in order to make myself eligible for benefits that I am not entitled to or apply for assistance at more than one site, I can be prosecuted for fraud and/or denied assistance in the future.
* I understand that the agencies involved in this program may verify all of the information which I have provided.
* (For residential applicants): I am the only person living in the household at the address shown on this form who has applied for this assistance; or
* (For commercial applicants): I am the only person who has applied for/on behalf of the account holder, including their successors, at the address shown on this form and that I am not a government account holder.

Printed Name (required)

Title (for Commercial Accounts) (required)

For Office Use Only

Date Received__________ Screened Date__________ Amount 60+ Past Due: $__________ Amount 30+ Past Due: $__________ Total: $__________