Fillable COVID-19 MUNICIPAL UTILITY RELIEF PROGRAM PAST DUE UTILITY

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COVID-19 MUNICIPAL UTILITY RELIEF PROGRAM PAST DUE UTILITY

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COVID-19 MUNICIPAL UTILITY RELIEF PROGRAM
PAST DUE UTILITY ASSISTANCE
CUSTOMER INTAKE FORM
*** This Customer Intake Form is available in additional languages at: bit.ly/FWoptions ***
This form must be completed and returned to Fairfax Water by November 1, 2021
for you to be considered for assistance that could lower the amounts you owe
for water and/or wastewater services.
Complete this form, sign it, and send it to Fairfax Water by one of the following means:
Email: COVIDrelief@fairfaxwater.org
Fax: 703.289.6292
Mail: Must be postmarked by November 1, 2021
Fairfax Water
ATTN: COVID Relief
8570 Executive Park Avenue
Fairfax VA, 22031
If you have questions about this program or would like to complete the application over the phone by
speaking with one of our Customer Service Representatives, please call our Customer Service Department at
703.698.5800 (TTY 711) weekdays between the hours of 8:00 am and 6:00 pm.
Program Description:
Fairfax Water and each locality providing wastewater service within our service area (Fairfax County, City of
Falls Church, and City of Fairfax - the “Participating Localities”) are participating in Virginia’s COVID-19
Municipal Utility Relief Program (the “Utility Relief Program”).
Under the Utility Relief Program, utility customers who meet the following criteria will be eligible to receive
utility relief assistance that could lower the amounts you owe for water and/or wastewater services during
March 1, 2020 through November 1, 2021. Customer eligibility criteria are as follows:
• The Customer’s water and wastewater bills for service between March 1, 2020 and November 1,
2021 are more than 30 days past due;
• The Customer has experienced an economic hardship resulting directly or indirectly from the
COVID-19 pandemic; and
• The Customer has not previously received CARES Act assistance for water or wastewater bills from any
other source. This may include, but is not limited to, assistance provided through the
Commonwealth’s Rebuild Virginia Grant Fund, the Fairfax County Non-Profit Sustainability Grant, or
the Fairfax County RISE Program. (Customers who have previously received assistance through the
COVID-19 Municipal Utility Relief Program may apply for assistance more than once).
In order to be considered for this assistance, you must complete, sign and submit the following Customer
Intake Form to Fairfax Water (or complete the Intake Form by phone) on or before November 1, 2021 with
Page 2 of 4
responses showing that you meet the customer eligibility criteria set forth above. The assistance comes
from an allocation of the utility relief funds awarded to Fairfax Water and the Participating Locality who
provides your wastewater service.
A. GENERAL INFORMATION
1. Full Legal Name of Account Holder:
2. Date of Application:
3. Fairfax Water Account Number:
4. Service Address:
Street:
City:
State: Zip:
5. Customer Phone Number:
6. Customer Email Address:
7. Customer Type:
Residential Non-Residential (Non-
Residential Customers must
submit a W-9 with this Customer
Intake Form)
B. NATURE OF ECONOMIC HARDSH
1. FOR RESIDENTIAL CUSTOMERS: COMPLETE THIS SECTION:
Residential Customers: Place a 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):
have 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 (describe)
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2. NON-RESIDENTIAL CUSTOMERS: COMPLETE THIS SECTION:
Non-Residential Customers: Provide property name and basis for economic hardship:
Property Name:
Are your unpaid utility bills due to the economic hardship experienced as a result of the COVID-19
pandemic? (select one below)
Yes (eligible for relief; provide explanation below)
Provide an explanation of the COVID-19-related economic hardship:
No (not eligible for relief)
C. REQUIRED CERTIFICATIONS FOR UTILITY RELIEF ASSISTANCE:
1. I desire to receive any assistance to which I may be legally entitled under this program and its
specifications.
2. I certify that the economic hardship(s) I have identified in Section B of this Customer Intake
Form is/are due to the COVID-19 pandemic and that the information set forth in Section B is
true and correct to the best of my knowledge and belief.
3. I hereby grant permission for the staff at Fairfax Water (and, as applicable, the Participating
Locality from which I obtain wastewater service) to review records as necessary to verify my
eligibility for assistance. I acknowledge and agree that Fairfax Water and the Participating
Localities may rely upon the certifications set forth in this Intake Form, including the declaration
set forth in Section B (above) that my utility fee arrearage is due to economic hardship resulting
from the COVID-19 pandemic, and any additional documentation I may be required to provide
to Fairfax Water or the Participating Locality.
4. I understand that Fairfax Water and the Participating Locality that provides my wastewater
service will use my customer account information and records to determine my utility relief, if
any.
5. I declare to the best of my knowledge that, as applicable to me (choose only one):
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 non-residential applicants: I am the only person who has applied for/on behalf
of the nonresidential account holder, including their successors, at the address
shown on this form and that I am not a government account holder. I will submit
a W-9 to Fairfax Water on or before November 1, 2021.
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6. I certify that the account holder has not received CARES Act relief for any of the arrearages for
which I am applying from any source (including but not limited to this Municipal Utility Relief
Program, Rebuild VA Grants, the Fairfax County Non-Profit Sustainability Grant, or the Fairfax
County RISE Program).
7. I understand that, if I give false information or withhold information in order to make myself
eligible for benefits to which I am not entitled, or if I apply for the same assistance at more than
one site, I can be prosecuted for fraud and/or denied assistance in the future.
8. I certify under penalty of perjury that the information set forth in this Customer Intake Form is
true and correct.
Signature
Date
Printed Name
Title (for non-residential account holders)
For Fairfax Water Staff Use:
Date Received by Fairfax Water:
Action Taken: Screener: Date Processed:
Eligible Amount – Water: Eligible Amount – Wastewater:
Amount Applied – Water: Amount Applied – Wastewater:
Application Taken Over the Phone
By:
Date:
Time:
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Completed 21 July 2021

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