Emergency Dispatch: (703) 335-7982
Customer Service: (703) 335-7950
 

COVID-19 Relief Program

I. ACCOUNT HOLDER INFORMATION
Account Holder (Full Name):
Account Number or Service Address:
Customer Phone Number:
Email Address:

II. ECONOMIC HARDSHIP: Please select one or more cause(s) of economic hardship that apply below.
Was laid off
Experienced a reduction in hours of work
Place of employment closed
Must stay home to care for children due to closure of day care and/or school
Have lost child or spousal support
Have been unable to work hours or days due to contracting COVID-19
Have been 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):
Applicant's Certification:
I desire to receive any assistance to which I am legally entitled under this program and its specifications.
The reason I am eligible for this CARES Act assistance is correct to the best of my knowledge and belief.
I declare to the best of my knowledge that I am the only person living in the household at the address shown on this form who has applied for this assistance.
Commercial and non-residential customers: I declare to the best of my knowledge I am the only person who has applied for relief funds on behalf of the 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 entity has not received CARES Act relief for any of the utility 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 the information I have provided.
I understand that submitting this form gives permission to the Prince William County Service Authority to which I am applying to verify information concerning my need for assistance.
I have read and certify all of the above
Cancel