COVID-19 UTILITY AFFIDAVIT
This form is to be completed by tenants who have applied for assistance with utility arrears. One form should
be used for each applicant who will be applying for assistance through the City of Fresno COVID-19 Emergency
Rental Assistance program.
Applicant Information
Applicant Name (First name, M.I., Last name): ____________________________________________________
Applicant Date of Birth: ________________________________________________________
Applicant Certification
By signing this form, I hereby certify that the above information is factual, accurate and complete. I agree to
immediately notify the City of Fresno and its affiliated Administrators of any changes to this information. I
understand that as a condition of participating in this program, the City of Fresno and its affiliated
Administrators are permitted to request additional verification if the information reported appears to be
inconsistent or incorrect. I understand that if I provide any false information or misrepresentation it will be
grounds for denying my participation in the Emergency Rental Assistance Program. By accepting these Terms
and Conditions, I give my consent (permission) to the City of Fresno, its contractors, consultants, and other
federal or state agencies (City Partners) including my utility provider. The Administrators are hereby
authorized to share information about my household's utility account, energy usage and/or other information
needed to provide services and benefits, including the payment of funds to the utility provider on behalf of my
household as described in this application. I also understand and consent to the release of this information
pursuant to the Public Records Act, to the extent required under California law.
Applicant Signature: _____________________________________________ Date: _______________________
__________________________________________________________________________________________
Utility Information (Utility information must be provided in order for utilities to be paid by the City of Fresno
COVID-19 Emergency Rental Assistance program)
Pacific Gas & Electric:
Account Number ____________________________ Name on Account ______________________________
City of Fresno Utilities:
Account Number ____________________________ Name on Account ______________________________
Internet Provider Company: _____________________________
Account Number ____________________________ Name on Account ______________________________
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