Fillable GENERAL INFORMATION (Rockbridge County)

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GENERAL INFORMATION (Rockbridge County)

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Country of origin: US
File type: PDF

U.S.A. forms for Rockbridge County

BROWSE ROCKBRIDGE COUNTY (VA) FORMS

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The RCPSA is an Equal Opportunity Provider and Employer.
GENERAL INFORMATION
1. Date of Customer’s Application: __________________
2. Account Number: _______
3. Past Due Amount (past due usages from March 1-December 30) ________________________
4. Street Address (where utility service is provided): __________________________________________
5. City or County (where utility service is provided: __________________________________________
6. State (where utility service is provided): __________________________________________
7. ZIP Code (where utility service is provided): __________________________________________
8. Customer Phone Number: ____________________________________
9. 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 (describe) _______________________________________________________
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:
__________________________________________________________________________________________
_______________________________________________________________
The RCPSA is an Equal Opportunity Provider and Employer.
This CARES Act assistance application:
• Will provide partial assistance for usage from March 1, 2020, to December 30, 2020, and may not be
used for past due amounts prior to this time period.
• 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
penalties, disconnection charges or other fees. These amounts are still due.
• Is understood that by completing this form does not guarantee funds will be awarded or if award
funds, that it will cover the entire outstanding balance.
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 Rockbridge County Public Service
Authority to verify records as necessary to verify my eligibility for assistance.
• I certify that this account/ 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.
• (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
holder.
____________________________ _________________________ ______________________________
Printed Name Signature Title (for commercial accounts)
For Office Use Only
Date Received
Screened Date
Service
60+ Past Due
30+ Past Due
Water
Sewer
Total
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GENERAL INFORMATION (Rockbridge County)

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Completed 11 December 2021

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