FCWSA COVID-19 Utility Relief Program Customer Intake Form

FAUQUIER COUNTY WATER AND SANITATION AUTHORITY
COVID-19 UTILITY RELIEF PROGRAM
Utility Arrearage Assistance
Customer Intake Form
1. Account Number *
2. Amount Due on Current Bill *
3. Street Address (where utility service is provided): *
4. City (where utility service is provided): *
5. State (where utility service is provided)
6. ZIP Code (where utility service is provided) *
7. Customer Phone Number *
8. Customer Type:

Residential Commercial
RESIDENTIAL CUSTOMERS COMPLETE THIS SECTION

1. Name of Residential Account Holder:
First M.I. Last
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):
been laid off;
place of employment has closed;
have experienced a reduction in hours of work;
must stay home to care for children due to closure of day care and/or school;
lost child or spousal support;
not been able to work or missed hours due to contracting COVID 19;
unable to find work due to COVID 19;
unwilling/unable to participate in previous employment due to high risk of illness from COVID 19;
other( if selecting this option please check the 'Other' box below and must enter description) Other
COMMERCIAL CUSTOMERS COMPLETE THIS SECTION
1. Name of Non Residential Account Holder
2. Property Name:
3. Is the utility fee arrearage due to economic hardship experienced by the customer as a result of the COVID-19 pandemic? (Check Y/N)

YES (Eligible for relief; provide explanation below) NO (Not eligible for relief)
4. Provide an explanation of the COVID 19 related economic hardship
This CARES Act assistance application:
- Will provide partial assistance for bills dated March 1, 2020, to November 01, 2021, and may not be used for past due amounts prior to this time period.
- 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 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.
Printed Name
Signature

Clear

For FCWSA Use Only
Date Received

Month Day Year
Date
Screened Date

Month Day Year
Date

Service	60+ Past Due	30+ Past Due

Should be Empty:

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FAUQUIER COUNTY WATER AND SANITATION AUTHORITY

COVID-19 UTILITY RELIEF PROGRAM

Utility Arrearage Assistance

Customer Intake Form