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Insert your account number or another unique identifier of your utility bill. If you are unsure of your account number, please call the Public Works office at 434-836-7135.
Please enter the address where utility service is provided.
Total Arrearage from March 1, 2020 – December 30, 2020 that is due. If you are unsure of the exact amount or don't have a statement, please call the Public Works office at 434-836-7135.
Please attach a statement from your municipal utility provider demonstrating the amount attached.
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)
If the answer is no than you are not eligible for this relief.
Please provide an explanation of the COVID-19 related economic hardship.
• 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 Pittsylvania County and Pittsylvania County Service Authority 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 (insert name of municipal utility) to which I am applying to verify information concerning my need for assistance.
This field is not part of the form submission.
* indicates a required field