FCWSA COVID-19 Utility Relief Program 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 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

Printed Name

Signature

Clear

Title (for commercial accounts)

FAUQUIER COUNTY WATER AND SANITATION AUTHORITY

COVID-19 UTILITY RELIEF PROGRAM

Utility Arrearage Assistance

Customer Intake Form