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 severe
illness from COVID‐19
NON‐RESIDENTIAL CUSTOMERS COMPLETE THIS SECTION
Name of Non‐Residential Account Holder:
Is the utility fee arrearage due to economic hardship experienced by the customer as a result of
he COVID‐19 pandemic? (Check Y/N)
YES (Eligible for relief; provide explanation below.)
NO (Not eligible for relief.)
Provide an explanation of the COVID‐19 related economic hardship:
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 or after 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‐
- Funding can be used for the following bills:
- 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
- I understand that my signature on this form gives permission for the staff at Town of Smithfield to verify
records as necessary to verify my eligibility for assistance.