COVID-19 Utility Relief Application

COVID-19 Municipal Utility Relief Program

Utility Arrearage Assistance Customer Intake Form
CARES Act assistance application may assist for bills dated March 1, 2020, to Dec. 30, 2020, and may not be used for past due amounts prior to 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 can be used for water and/or wastewater bills.
- ONLY active Chesapeake Public Utilities customers need apply.
- Limited funds are on a first-come-first-served basis.
- The application deadline has been extended until funds have been exhausted.
General Information

All applicants fill out this section.
Account Number or Other Unique Identifier of the Customer Utility Bill
Chesapeake Public Utilities will use this information to help determine the total arrearage from March 1 to Dec. 30, 2020.
Total Arrearage from March 1, 2020 to Dec. 30, 2020 that is due
Street Address where utility service is provided:
Must be a Chesapeake address
ZIP Code where utility service is provided:
Customer Phone Number
Please include area code and number
Customer Type

Residential Non-Residential

Residential Customer Information

Only Residential Applicants fill in this section, i.e. single family dwellings, parsonages, multi-family dwellings, etc.
Name of Residential Account Holder

First Name Middle Initial Last Name
Maiden Name if applicable
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.

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)

Non-Residential Customer Information

Only Non-Residential Applicants fill in this section, i.e. business locations, business owners, religious facilities, etc.
Name of Residential Account Holder

First Name Middle Initial Last Name
Maiden Name if applicable
Property Name
Is the utility fee arrearage due to economic hardship experienced as a result of the COVID-19 pandemic?

NO. Not eligible for relief YES. Eligible for relief.
If your utility fee arrearage is NOT due to economic hardship experienced as a result of the COVID-19 pandemic, you are NOT eligible for CARES Act assistance. If you have any questions, contact the Chesapeake Public Utilities Department at water@cityofchesapeake.net or 757-382-6352.
Provide an explanation of the COVID-19 related economic hardship to your non-residential property.

Applicant’s Certification

Signature and Terms for both residential and nonresidential customers.
By signing this form, I confirm:
- 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 the CITY OF CHESAPEAKE 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 CITY OF CHESAPEAKE to which I am applying to verify information concerning my need for assistance.
Name

First Name Middle Initial Last Name
Title in the Company
For non-residential account holders, i.e. owner, president, treasurer
Signature

Clear
Applicant's email address:
For email confirmation and possible follow-up.
Application Date

Month Day Year
If you have any questions or concerns, contact the Public Utilities Department:
water@cityofchesapeake.net
757-382-6352
Should be Empty:

COVID-19 Municipal Utility Relief Program

General Information

Residential Customer Information

Non-Residential Customer Information

Applicant’s Certification