COVID‐19 Municipal Utility Relief Program Application

15 digit utility account number*

This needs to be 15 digits; no spaces or commas or dashes - include all leading or trailing zeros

Delinquent bills with consumption from March 1, 2020 - December 30, 2021 excluding refuse/trash service, late fees, deposits and other miscellaneous fees.

Henrico DPU will provide an exact dollar amount when processing this application and will contact you with this information. If unknown, please leave blank.

Address

Street Address City State ZIP Code

Customer Daytime Phone Number*

Customer Nighttime Phone Number*

Alternate Phone Number

Email*

Customer Type*

Residential
Non-Residential

Name of Residential Account Holder*

First Middle Last

Name of Non-Residential Account Holder/Applicant*

First Middle Last

Business Name*

Is the utility fee arrearage due to economic hardship experienced by the customer as a result of the COVID‐19 pandemic?*

Yes (Eligible for relief, provide a detailed explanation below.)
No (Not eligible for relief.)

Is the past due balance due to economic hardship experienced by the customer as a result of the COVID‐19 pandemic?*

Yes (Eligible for relief.)
No (Not eligible for relief.)

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

If "other" please describe*

Provide an explanation of the COVID‐19 related economic hardship*

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 Henrico County to verify records as necessary to verify my eligibility for assistance.
I declare to the best of my knowledge that:
- (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
- (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 Henrico County Department of Public Utilities to which I am applying to verify information concerning my need for assistance.

*

Yes, I confirm that I have read and agree to the Applicant’s Certification.

*

I understand if I have not received final confirmation from Public Utilities within 30 days of my application, that I am responsible to follow up with DPU and failure to do so will result in not receiving the funding assistance.

The COVID‐19 Municipal Utility Relief Program is for people experiencing economic hardship due to the Covid-19 pandemic.

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COVID‐19 Municipal Utility Relief Program Application

APPLICATION DEADLINE

CARES Act assistance application may: