Fillable TOWN OF SMITHFIELD COVID19 UTILITY RELIEF PROGRAM Utility (Town of Smithfield)

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TOWN OF SMITHFIELD COVID19 UTILITY RELIEF PROGRAM Utility (Town of Smithfield)

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The TOWN OF SMITHFIELD COVID19 UTILITY RELIEF PROGRAM Utility (Town of Smithfield) form is 3 pages long and contains:

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  • 2 check-boxes
  • 32 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Smithfield

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TOWN OF SMITHFIELD COVID‐19 UTILITY RELIEF
PROGRAM
Utility Arrearage Assistance
GENERAL INFORMATION
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):
6.
State (where utility service is provided):
7.
ZIP Code (where utility service is provided):
8.
Customer Phone Number:
9.
Customer Type:
Residential
Non‐Residential
RESIDENTIAL CUSTOMERS COMPLETE THIS SECTION
1.
Name of Residential Account Holder:
First M.I. Last (Maiden)
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 severe
illness from COVID‐19
other (describe)
NON‐RESIDENTIAL 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
t
he COVID‐19 pandemic? (Check Y/N)
4.
YES (Eligible for relief; provide explanation below.)
5.
NO (Not eligible for relief.)
6.
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‐
residential).
- Funding can be used for the following bills:
Water
Wastewater
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 Town of Smithfield 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 Town of Smithfield to which I am applying to
verify information concerning my need for assistance.
- Others?
Printed Name Signature
Title (for non‐residential account holders)
Municipal Utility Intake Information: ACTION TAKEN
Screener
Date
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TOWN OF SMITHFIELD COVID19 UTILITY RELIEF PROGRAM Utility (Town of Smithfield)

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Completed 24 January 2021

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