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Customer Intake Form - Utility Relief Program

  1. Hanover County

    COVID-19 MUNICIPAL UTILITY RELIEF PROGRAM
    Utility Arrearage Assistance
    Customer Intake Application

  2. General Information

  3. Customer Type:

  4. For residential customers:

    Check 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)

  5. Have you or are you expecting to receive assistance from another program to pay your delinquent water/sewer bill?

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

  7. Have you or are you expecting to receive assistance from another program to pay your delinquent water/sewer bill?

  8. CARES Act assistance application may:

    • Assist for bills dated May 19, 2020, to November 19, 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 obtained under this application may be used for water and sewer bills due to Hanover County Public Utilities.
  9. 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 Hanover 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 accountholder, including their successors, at the address shown on this form and that I am not a government accountholder.
    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 that my signature on this form gives permission to Hanover County to which I am applying to verify information concerning my need for assistance.

  10. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  11. Leave This Blank:

  12. This field is not part of the form submission.