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COVID-19 Utility Assistance Intake Form - Non-Residential Customers

2. COVID-19 Utility Assistance Intake Form - Non-Residential Customers
   Submission of an application does not guarantee any or all of a customer’s account arrearages will be offset by CARES Utility Relief Funds.

   Submission of an application does not guarantee any or all of a customer’s account arrearages will be offset by CARES Utility Relief Funds.

4. Name of Non‐Residential Account Holder:*

6. Property Name:

8. Utility Billing Customer Account Number:*

10. Address where utility service is provided:

12. Street:*

13. Unit:

15. City:*

16. Zip Code:*

18. Phone Number:*

19. Fax Number:

21. Email Address:

23. Is the utility fee arrearage due to economic hardship experienced by the customer as a result of the COVID‐19 pandemic? (Check Y/N)*

    1. YES (Eligible for relief; provide explanation below.)

    1. NO (Not eligible for relief.)

25. Provide an explanation of the COVID‐19 related economic hardship below:*

27. CARES Act assistance application may:

29. - 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 or after this time period.

31. - Funding is designed to be a one‐time opportunity, for the account holder and their successors.

33. - Funding can be used for the following bills:*

    1. Water

    1. Wastewater

    1. Gas

35. 

37. Name:*

    Electronic Signature- By adding your name here you agree that everything above is correct and submitted by you.

38. Date*
    Date

40. Title (for non‐residential account holders)

Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field