• FAUQUIER COUNTY WATER AND SANITATION AUTHORITY

  • COVID-19 UTILITY RELIEF PROGRAM

  • Utility Arrearage Assistance

  • Customer Intake Form

  • RESIDENTIAL CUSTOMERS COMPLETE THIS SECTION

    1. Name of Residential Account Holder:

  • 2. For residential customers: place mark beside the 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):

  • COMMERCIAL CUSTOMERS COMPLETE THIS SECTION

  • This CARES Act assistance application:

    • Will provide partial assistance for bills dated March 1, 2020, to November 30, 2020, and may not be used for past due amounts prior to this time period.
    • Can not be used by customers who have received CARES act relief for arrearages on this account.
    • Is designed to be a one-time opportunity, with only one payment per household (for residential) or account holder and their successors (for non-residential).
    • May only be used to pay water and sewer consumption and base charges. It will not be applied to deposits or late 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 Fauquier County Water and Sanitation Authority to verify records as necessary to verify my eligibility for assistance.
    • I certify that I have not received CARES act relief for any of the arrearages on this account.
    • 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
  • Clear
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  • Should be Empty:
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