Fillable Form 22: Utility Arrearage Assistance Customer Intake Form (City of Portsmouth, VA)

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Form 22: Utility Arrearage Assistance Customer Intake Form (City of Portsmouth, VA)

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The Form 22: Utility Arrearage Assistance Customer Intake Form (City of Portsmouth, VA) form is 2 pages long and contains:

  • 1 signature
  • 16 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Portsmouth, VA

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GENERAL IN
FORMATION (All Applicants fill in this section.)
1. Date of Customer’s Application: ___________
2. Account Number or Other Unique Identifier of the Customer Utility Bill: ___________________
3. Total Arrearage from March 1, 2020 – December 30, 2020 that is due (Provided by Municipal Utility with statement
demonstrating amount attached): ______________
4. Street Address (where utility service is provided): __________________________
5. City or County (where utility service is provided): PORTSMOUTH
6. State (where utility service is provided): VIRGINIA
7. ZIP Code (where utility service is provided): ____________
8. Customer Phone Number: ______________
9. Customer
Type: Residential Non-Residential
RESIDENTIAL CUSTOMERS COMPLETE THIS SECTION
(Only Residential Applicants fill in this section, i.e. single family dwellings, parsonages, multi-family dwellings, etc.)
1. Name of Residential Account Holder:
____________ __________ ____________________ _____________________
First Name M.I. Last Name (Maiden Name)
2. For residential customers: select the applicable causes 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 mis
sed hours due to contracting COVID-19;
_____ unable to find work due
to COVID-19;
_____ unwilling/unable t
o participate in previous employment due to high risk of severe illness from COVID-19
_____ other (describ
e)
COVID-19 MUNICIPAL UTILITY RELIEF PROGRAM
Utility Arrearage Assistance
Customer Intake Form
(ONLY active
Portsmouth
Public Utilities customers need apply. Complete this form, print, sign (pdf signatures acceptable),
and
place in
Public Utilities’ drop box outside City Hall,
801 Crawford Street or email portsmouthutilityrelief@portsmouthva.gov
by midnight
January
22
,
202
1
. Applications cannot be considered past this deadline. Limited funds are on a first-come-first-served basis.)
Client Intake Form
2
NON-RESIDENTIAL CUSTOMERS COMPLETE THIS SECTION
(Only Non-Residential Applicants fill in this section, i.e. business locations, business owners, religious facilities, etc.)
1. Name of Non-Residential Account Holder:
____________ __________ ____________________ _____________________
First Name M.I. Last Name (Maiden Name)
2. Property Name: ___________________________________________________________
3. Is the utility fee arrearage due to economic hardship experienced as a result of the COVID-19 pandemic?
_____ NO (Not eligible for relief.) _____ YES (Eligible for relief; provide explanation below.)
4. Provide an explanation of the COVID-19 related economic hardship to your non-residential property:
________________________________________________________________________________
CARES Act assistance application may:
- Assist for bills dated March 1, 2020, to December 30, 2020, and may not be used for past due amounts prior to
this time period.
- Funding 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).
- Funding can be used for water and/or wastewater bills.
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 staff at the CITY OF PORTSMOUTH to verify records as necessary to verify my
eligibility for assistance.
- I declare to the best of my knowledge that:
o (1) 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
o (2) for non-residential applicants: I am the only person who has applied for/on behalf of the non-residential account holder, including their
successors, at the address shown on this form and that I am not a government account holder.
- I certify that this customer has not received CARES act relief for any of the arrearages I am applying for from any other source including Rebuild VA
Grants.
- 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.
- I understand and my signature on this form gives permission to CITY OF PORTSMOUTH to which I am applying to verify information concerning my
need for assistance.
(Residential and Non-Residential Applicants Sign Here)
____________ __________ ____________________ ______________________________
First Name M.I. Last Name Signature
______________________________
Title in the Company (For non-residential account holders, i.e. owner, president, treasurer)
Municipal Utility Intake Information
Screener First Name: _______________ Last Name: _______________________ Date: __________
ACTION TAKEN: _____ Approved _____ Not Approved _____ Pending More Information
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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Form 22: Utility Arrearage Assistance Customer Intake Form (City of Portsmouth, VA)

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Completed 19 January 2021

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