COVID-19 UTILITY RELIEF PROGRAM Utility Arrearage Assistance

DEADLINE EXTENDED UNTIL FURTHER NOTICE (as of Jan. 13, 2021)

 

Customer Intake Form

RESIDENTIAL CUSTOMERS – COMPLETE THIS SECTION

COMMERCIAL CUSTOMERS – COMPLETE THIS SECTION

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.

For Office Use Only

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