FCWSA COVID-19 Payment Arrangement Agreement

FCWSA COVID-19 Payment Arrangement

This payment arrangement agreement ("Agreement") is being made between the Fauquier County Water and Sanitation Authority ("Authority") and the Owner, Landlord, or Tenant ("Customer") as specified below.
Customer Information:
Customer's Full Name *

First Name Last Name
Service Address *
Service Account Number *
Customer's Current Employer *
Customer's SSN (Last 4) *

Terms:

To cover past due amounts owed to the Authority, the Customer agrees to make the following payment plan for a period between 6 to 24 months in addition to their current monthly bill:
Type a question *

Equal Monthly Payments
In the amount of *
Payment arrangement amount
By 4:30 p.m. on the *
Day of the month (e.g. Third Tuesday, or 15th of month)
Day of every month over the course of the next *
Number of months (6 to 24)
Beginning on the *
Start date (e.g. 3rd)
Day of *
Month (e.g. January)
In the Year *
Year (e.g. 2021)
I am attesting that I am experiencing an economic hardship due to the COVID-19 pandemic, and am asking for a COVID-19 relief payment plan authorized by the Commonwealth of Virginia. I understand that I am to pay all balances based on this plan and that if my financial circumstances are further impacted by the pandemic I need to contact the Fauquier County Water and Sanitation Authority immediately to update my payment plan. I understand that I must continue to pay the current charges due in addition to my payment plan.
Acknowledgement:
Customer Signature

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