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COVID-19 Municipal Utility Relief Program


    Utility Arrearage Assistance Customer Intake Form
    (ONLY active Newport News Waterworks customers need apply.
    (*Assistance will be available until funds have been depleted*)

  2. General Information (All Applicants fill in this section.)

  3. Type of Account *
  4. For residential customers: select the applicable causes 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. Only Non-Residential Applicants fill in this section, i.e. business locations, business owners, religious facilities, etc.

  6. Is the utility fee arrearage due to economic hardship experienced as a result of the COVID-19 pandemic?
  7. Choose One:
  8. CARES Act assistance application may:
    •    Funds may not be used for past due amounts prior to March 1, 2020.
    •    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 can be used for water and/or wastewater bills.
  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 submission of this form gives permission for the staff at Newport News Waterworks 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 Newport News Waterworks to which I am applying to verify information concerning my need for assistance.
  10. (Residential and Non-Residential Applicants Sign Here)
  11. I agree, and acknowledge that checking this box constitutes an electronic signature for purposes of this form*
  12. Internal Use Only
  13. CSR Rep Name Here

  14. Action Taken:
  15. Leave This Blank:

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