Fillable Virginia Beach Public Utilities Water Assistance Program Applicant (City of Virginia Beach)

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Virginia Beach Public Utilities Water Assistance Program Applicant (City of Virginia Beach)

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Rev. 06/2018
Virginia Beach Public Utilities
Water Assistance Program
Applicant Information
Full
Name:
Last
First
M.I.
Address:
Street Address
Apartment/Unit #
City
State
Phone:
Alt. Phone:
Email:
Date of Birth:
CoApplicant Information (as
listed on Public Utilities account)
Full Name:
Last
First
M.I.
Date of Birth:
Social Security:
All Household Members
Name Relationship to Applicant Date of Birth Social Security Number
There are no other individuals living in the home (initial)
Total Household Income
Gross Wages (before taxes)
$
per
Child Support
$
per
Financial Assistance (TANF, SSI, SSA, etc.)
$
per
Other
$
per
Total Household Income
$
per
City of Virginia Beach
Department of Human Services
Social Security:
Rev. 06/2018
Household Employment History
Applicant Employment Information
Place of Employment:
Dates of Employment:
Address:
I (print your name)
do not have income or resources at this time.
Public Utilities Account Information
Name(s) on Account:
Account Number: _ _ _ - _ _ _ _ _ _ _ - _ _ _ _ _ _ _
Disclaimer and Signature
I request assistance and certify that the contents of this application are true and correct. I understand that:
- I have the right to file a complaint if I feel that I have been discriminated against because of my race, color, national
origin, religion, sex, age, handicap or religious belief.
- If I give false information or withhold information, I may be breaking the law and could be prosecuted for perjury or
larceny.
- My signature below authorizes the Department of Human Services and the Department of Public Utilities to share
information and obtain any written verification necessary to establish my eligibility for assistance and give information
in my case record to other organizations from which I have or may request assistance.
My signatur
e below also indicates my understanding of the following:
- I am aware that in order to qualify for the Water Assistance Program (WAP), I will be required to pay down any
amount in excess of $300.00 before becoming eligible for an assistance payment. Payments must be made in
person at the City of Virginia Beach Treasurer's Office. Accepted forms of payments are cash, cashier's check, or
money order only.
Any other forms of payment will result in a delay of assistance.
- While I am receiving assistance from the WAP, I am still res
ponsible for any bills I receive from the Virginia Beach
Department of Public Utilities.
- If I receive a bill and do not pay that bill by the due date, my water service will be terminated.
- During the time that my WAP payment is being processed, I may receive a delinquent notice or a telephone call
notifying me that my service may be terminated.
Household Employment Information
Household Member:
Place of Employment:
Dates of Employment:
Address:
Household Member:
Place of Employment:
Dates of Employment:
Address:
Household Member:
Place of Employment:
Dates of Employment:
Address:
Signature:
Date:
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Virginia Beach Public Utilities Water Assistance Program Applicant (City of Virginia Beach)

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Completed 4 June 2021

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