Please put the first and last name or N/A if this is a commercial account.
Please put N/A if this is a resident account.
Provide a name for a person who can provide additional information if needed. Please put N/A if you are a contact person.
Provide a phone number for the contact person.
For residential customers, please check the applicable cause(s) 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).
If the box "Other" was checked please provide an explanation.
What is the property name?
Is the utility fee arrearage due to economic hardship experienced by the customer as a result of the COVID-19 pandemic?
Provide an explanation of the COVID-19 related economic hardship.
This CARES ACT assistance application: Will provide partial assistance for bills dated March 1, 2020, to October 31, 2020, and may not be used for past due amounts prior to this time period.
Can not be used by customers who have received utility assistance through the Community First Water Utility Grant (CDBG) in June- July
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 stormwater charges or refuse charges. These amounts are still due.
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 City of Colonial Heights 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 or Community First Water Utility Grant (CDBG).
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.
This field is not part of the form submission.
* indicates a required field