The RCPSA is an Equal Opportunity Provider and Employer.
1. Date of Customers 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
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) _______________________________________________________
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
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
(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
____________________________ _________________________ ______________________________
Printed Name Signature Title (for commercial accounts)
For Office Use Only
Date Received
Screened Date
60+ Past Due
30+ Past Due