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COVID 19 - Municipal Utility Relief Program

  1. Utility Arrearage Assistance: Customer Intake Form
  2. Have you previously received MURP funds from the City of Fredericksburg?*
  3. Customer Type:
  4. Residential Customers Complete this Section
  5. First MI Last (Maiden)
  6. For residential customers: place 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):
  7. Nonresidential Customers Complete this Section
  8. Is the utility fee arrearage due to economic hardship experienced by the customer as a result of the COVID 19 pandemic?
    (Check Y or N)
  9. Applicants Certification:
    - I desire to receive any assistance to which I am legally entitled under this program and its specifications.
  10. - I certify that the reason I am eligible for this CARES Act assistance is correct to the best of my knowledge and belief.
  11. - I understand that my signature on this form gives permission for the staff at the City of Fredericksburg to verify records as necessary to verify my eligibility for assistance
  12. - I declare to the best of my knowledge that:
  13. (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
  14. (2) for nonresidential 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.
  15. 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.
  16. 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.
  17. I understand that the agencies involved in this program may verify all of the information that I have provided. I understand and my signature on this form gives permission to the City of Fredericksburg to which I am applying to verify information concerning my need for assistance.
  18. I am the account holder and have the authority to make this request. Further, I acknowledge the conditions listed above.*
  19. Leave This Blank:

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