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About

The Chesterfield CARES Water Assistance Program is administered through the Chesterfield County Department of Social Services. This program provides water and wastewater assistance with funding from the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which requires applicants to submit the information requested in this application. All submitted information will be kept confidential.

Applications should be submitted by Monday, Nov. 30, 2020. Applications will be reviewed as they are submitted. Please note that completing this application does not guarantee funds for water and wastewater assistance.

Once an application is submitted, the process steps are:

Program eligibility is established
Supporting documentation is verified
A funding decision is made

Initial funding assistance amount will not exceed $500. Depending on funding availability on or after Dec. 1, 2020, if household income has not increased and assistance for past due balances is still required, applicants may be eligible for up to $200 in additional funding assistance. Customers that receive CARES economic hardship grant assistance will provide approval to allow the payment to be applied to their utility account indicated in the application to continue to receive essential services.

Completing this application by including all requested information and documentation (via upload attachment) will decrease the time needed to process the application.

Requirements

The following requirements apply:

Applicants must live in Chesterfield County and have an active residential Chesterfield County utility water and/or wastewater account.
Applicants must have a past due balance on their residential water and/or wastewater account within the March 1 to Nov. 30, 2020 time frame.
During the period of time between March 1 and Nov. 30, 2020, at least one household member has been furloughed, laid off, unemployed or under-employed due to COVID-19; been unable to find a job due to COVID-19; had to leave or quit their job due to COVID-19 illness; or had to leave or quit their job to care for someone with COVID-19.
Households should provide documentation of circumstances described in Section 3 if available (examples include documentation of business closing, pre/post COVID-19 banking account statements, an unemployment letter, notice of furlough or layoff, one paystub from before March 1 and one paystub from after March 1 which shows a decrease in income due to COVID-19, etc.).

Chesterfield CARES Programa de Asistencia para el Pago de Servicio de Agua

El programa para la Asistencia con el Pago del Servicio de Agua Chesterfield CARES, es administrado por medio del Departamento de Servicios Sociales de Chesterfield; este programa provee asistencia con el pago de los servicios de agua y drenaje con fondos del Acto de Ayuda, Desahogo y Seguridad Económica por el Coronavirus. (CARES Act, por sus siglas en inglés), el cual requiere que sus solicitantes entreguen la información mencionada en esta solicitud. Toda la información entregada se mantendrá confidencial.

Las solicitudes deben ser realizadas antes del 30 de noviembre de 2020. Las aplicaciones se revisarán en el momento en que se reciban. Por favor, tome en cuenta que el hecho de hacer una solicitud no garantiza que se le brinde asistencia con el pago de los servicios de agua y drenaje.

Una vez que se realiza la solicitud, los pasos a seguir son los siguientes:

Se establece su elegibilidad para el programa
La documentación de soporte es verificada
Se toma la decisión de si se brindará la asistencia financiera

La asistencia financiera inicial no excederá los $500. Dependiendo de la disponibilidad de los fondos en o después del 1 de diciembre de 2020, si el ingreso del hogar no ha aumentado y la asistencia financiera aún es requerida para el pago de saldos vencidos, los solicitantes pudieran ser elegibles por hasta $200 de asistencia financiera adicional. Los clientes que reciben ayuda de la beca CARES debido a dificultades económicas proporcionarán aprobación para permitir que el pago se aplique a su cuenta de servicios públicos que está indicada en la solicitud si quieren seguir recibiendo servicios esenciales.

El completar esta solicitud incluyendo toda la información y documentación requerida (subiendo el archivo) reducirá el tiempo necesario para procesar la solicitud.

Requisitos

Los siguientes requisitos son aplicables:

Los solicitantes deben vivir en el Condado de Chesterfield y tener una cuenta residencial activa de Servicios de Agua y/o Drenaje en el Condado de Chesterfield.
Los solicitantes deben tener un saldo atrasado en su cuenta residencial de Servicios de Agua y/o Drenaje dentro del período de 1 de marzo de 2020 y 30 de noviembre de 2020.
Durante el período entre el 1 de marzo y el 30 de noviembre de 2020, al menos un miembro del hogar debe haber sido suspendido, despedido, desempleado o subempleado debido a COVID-19; no haber podido encontrar un trabajo debido a COVID-19; dejar o renunciar a su trabajo debido a la enfermedad COVID-19; o dejar renunciar a su trabajo para cuidar a alguien con COVID-19.
De estar disponible, los individuos deben tener documentación de la circunstancias descritas en la Sección 3 (los ejemplos incluyen: Documentación que pruebe el cierre del negocio, estados de cuentas bancarios de antes y después del COVID-19, carta de desempleo, aviso de empleo sin goce de sueldo o despido del trabajo, una colilla de cheque (1) de antes del 1 de marzo y una (1) de después de esa fecha donde se muestre que se ha experimentado una disminución del ingreso debido al COVID-19.)

Status

Form ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Customer Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Customer-Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

CCWAP Eligible? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Pledge amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Reason {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Additional files {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Upload documents here for additional verification.

Other verification method {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

DSS Staff {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Date eligibility determined {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

English

Preliminary verification {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Preliminary verification {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

	Yes	No
{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

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{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

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Due to one or more responses above, you do not meet the eligibility requirements for this program.

Please contact our office at 804-748-1100 if you have any questions or concerns.

Verification requirements not met {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Spanish

Verificación preliminar {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Verificación preliminar {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

	Si	No
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{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

Due to one or more responses above, you do not meet the eligibility requirements for this program.

Please contact our office at 804-748-1100 if you have any questions or concerns.

Verification requirements not met {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

English

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Spanish

Nombre {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Nombre {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Teléfono {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Teléfono {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Correo Electrónico {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Correo Electrónico {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Dirección {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Dirección {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

English

Chesterfield County utility account customer number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

If you need to verify your account/customer number, call Chesterfield Utilities' Billing and Customer Service at 804-748-1291, Monday through Friday, 8:30 a.m.-5 p.m. excluding holidays.

Names of the individuals on the water/wastewater account

Individual on water/wastewater account {binding ItemNumber}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Are you behind in your water/wastewater payments? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Months you are requesting assistance paying water/wastewater bill {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Bills must be dated March 1, 2020 or after

Total amount of assistance requesting for water/wastewater bill {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Initial funding assistance amount will not exceed $500

Please select any of the following that apply to your household {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Last date of work {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Last date support received {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

How many people, including yourself, other adults and children, live in your home? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Household individuals

List all individuals, related and unrelated, currently living in the home. This includes adults, children, roommates, etc. The list of individuals below should equal the household size indicated above.

Household individual {binding ItemNumber}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date of birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Individual is an adult

{binding SSN_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

SSN only needed for adult household members.

{binding MonthlyIncomeBeforeCOVID19_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

If there is no income, please enter "0"

{binding MonthlyIncomeDuringCOVID19_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

If there is no income, please enter "0"

{binding SourceOfIncome_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding NameOfEmployer_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding FinancialLossDueToCOVID_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Spanish

Cuenta de Servicios del Condado de Chesterfield Número de Cliente {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

If you need to verify your account/customer number, call Chesterfield Utilities' Billing and Customer Service at 804-748-1291, Monday through Friday, 8:30 a.m.-5 p.m. excluding holidays.

Names of the individuals on the water/wastewater account

Nombre de las personas en la cuenta de servicios de agua y drenaje {binding ItemNumber}

Nombre {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

¿Está atrasado en los pagos de los Servicios de Agua/Drenaje? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Meses para los cuáles está pidiendo asistencia con el pago de la factura de Servicios de Agua/Drenaje (La(s) factura(s) debe(n) tener fecha de 1 de Marzo de 2020 o posterior {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Bills must be dated March 1, 2020 or after

Monto Total de Asistencia requerida para el pago de la factura de Servicios de Agua y Drenaje {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Por favor seleccione los que apliquen a su Hogar {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Último día de trabajo {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Último día que se recibió la manutención {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

¿Cuántas personas, incluyéndose usted, otros adultos, niños/bebés, viven en su hogar? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Household individuals

Liste todos los individuos, que sean o no parte de su familia, que actualmente vivan en su hogar. Esto incluye adultos, niños, bebés, personas que viven en su hogar, etc. La lista de individuos debe coincidir con el número de personas que se indicó arriba.

Household individual {binding ItemNumber}

Nombre {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Fecha de Nacimiento {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Individual is an adult

{binding NúmeroDeSeguroSocialParaParentSectionNombre_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

SSN only needed for adult household members.

Liste el ingreso total mensual, antes de impuestos de todos los miembros del hogar Esto incluye: sueldos, salarios y propinas; otro Ingreso como pensión para esposa/o, manutención de los niños, Seguro Social, SSI, desempleo, pensión, retiro, discapacidad

{binding ParentSectionNombreFirstsIngresoMensualAntesDelCOVID19_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

If there is no income, please enter "0"

{binding ParentSectionNombreFirstsIngresoMensualDuranteElCOVID19_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

If there is no income, please enter "0"

{binding ParentSectionNombreFirstsFuenteDeIngreso_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding ParentSectionNombreFirstsNombreDelEmpleador_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

¿Experimentó pérdida financiera debido al COVID-19? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

English

Optional: Take a photo or upload a scanned copy of a recent water/wastewater bill {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Upload proof of hardship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Examples include unemployment letter, notice of furlough or layoff, one paystub from before March 1 and one paystub from after experiencing a decrease in income due to COVID-19, etc.

Spanish

Opcional: Tome una foto o suba una copia escaneada de la factura más reciente de agua/drenaje. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Prueba de dificultad financiera {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Ejemplos: Carta de desempleo, carta de empleo sin goce de sueldo o despido, una colilla de antes del 1 de marzo y una posterior a cuando experimentó la disminución del ingreso debido al COVID-19, etc.

English

I required assistance in reading, obtaining and/or filling out this application due to limitations in access to the internet and/or the ability to understand how to fill out this form. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Because I required assistance, I am hereby assigning a third party authorization solely for the purpose of completing and submitting this application. This third party authorization is only binding for purposes of completing and submitting this application and could be revoked by me at any time. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Name of individual granted third party authorization {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

I certify that the above statements and attachments are true and correct to the best of my knowledge. I understand that providing false information shall result in disqualification of benefits and obligation to repay any funds previously received. I understand that I am receiving this CARES economic hardship grant assistance and I direct the funds to be paid directly to my residential utility account indicated in the application so that I may continue to receive essential services.

I understand that in requesting assistance from the Chesterfield CARES Water Assistance Program, the information and documentation provided in this application, including any social security numbers and any other information gathered during the application process, may be shared with other agencies to determine eligibility for assistance. By signing this form, I am also authorizing other agencies including Chesterfield County Utilities to exchange account information about me and my household with the Department of Social Services.

Electronic signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Electronic signature of individual granted third party authorization {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Spanish

Requerí asistencia para leer u obtener/llenar esta solicitud debido a limitaciones para el acceso a internet y/o la habilidad de comprender como llenar esta forma. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Por este medio y solamente con el propósito de completar y enviar esta solicitud, le asigno autorización a un tercero. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Nombre del Tercero autorizado {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Certifico que las declaraciones aquí descritas y documentos son correctos y verdaderos, a mi saber y entender. Entiendo que, el proveer información falsa puede resultar en una descalificación para la obtención de beneficios y la obligación de la devolución de cualquier fondo previamente recibido. Comprendo que recibo la beca CARES debido a dificultades económicas, y yo quiero que el pago se aplique directamente a mi cuenta de servicios públicos residenciales que está indicada en la solicitud para que yo pueda seguir recibiendo servicios esenciales.

También entiendo que, al requerir asistencia del Programa Chesterfield CARES para el Pago de Servicios de Agua, la información y documentación otorgada en esta solicitud, incluyendo números de seguro social, y cualquier otra información acumulada durante el proceso de solicitud, podría ser compartida a otras agencias para determinar la elegibilidad para dicha asistencia. Al firmar esta solicitud, también estoy autorizando a otras agencias, incluido el Departamento de Servicios Públicos de Chesterfield, el intercambiar información de la cuenta referente a mi persona y mi hogar con el Departamento de Servicios Sociales.

Firma electrónica del solicitante {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Firma electrónica del Tercero autorizado {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Language/Idioma {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

About

Once an application is submitted, the process steps are:

Program eligibility is established
Supporting documentation is verified
A funding decision is made

Completing this application by including all requested information and documentation (via upload attachment) will decrease the time needed to process the application.

Requirements

The following requirements apply:

Applicants must live in Chesterfield County and have an active residential Chesterfield County utility water and/or wastewater account.
Applicants must have a past due balance on their residential water and/or wastewater account within the March 1 to Nov. 30, 2020 time frame.
During the period of time between March 1 and Nov. 30, 2020, at least one household member has been furloughed, laid off, unemployed or under-employed due to COVID-19; been unable to find a job due to COVID-19; had to leave or quit their job due to COVID-19 illness; or had to leave or quit their job to care for someone with COVID-19.
Households should provide documentation of circumstances described in Section 3 if available (examples include documentation of business closing, pre/post COVID-19 banking account statements, an unemployment letter, notice of furlough or layoff, one paystub from before March 1 and one paystub from after March 1 which shows a decrease in income due to COVID-19, etc.).

Chesterfield CARES Programa de Asistencia para el Pago de Servicio de Agua

Una vez que se realiza la solicitud, los pasos a seguir son los siguientes:

Se establece su elegibilidad para el programa
La documentación de soporte es verificada
Se toma la decisión de si se brindará la asistencia financiera

El completar esta solicitud incluyendo toda la información y documentación requerida (subiendo el archivo) reducirá el tiempo necesario para procesar la solicitud.

Requisitos

Los siguientes requisitos son aplicables:

Los solicitantes deben vivir en el Condado de Chesterfield y tener una cuenta residencial activa de Servicios de Agua y/o Drenaje en el Condado de Chesterfield.
Los solicitantes deben tener un saldo atrasado en su cuenta residencial de Servicios de Agua y/o Drenaje dentro del período de 1 de marzo de 2020 y 30 de noviembre de 2020.
Durante el período entre el 1 de marzo y el 30 de noviembre de 2020, al menos un miembro del hogar debe haber sido suspendido, despedido, desempleado o subempleado debido a COVID-19; no haber podido encontrar un trabajo debido a COVID-19; dejar o renunciar a su trabajo debido a la enfermedad COVID-19; o dejar renunciar a su trabajo para cuidar a alguien con COVID-19.
De estar disponible, los individuos deben tener documentación de la circunstancias descritas en la Sección 3 (los ejemplos incluyen: Documentación que pruebe el cierre del negocio, estados de cuentas bancarios de antes y después del COVID-19, carta de desempleo, aviso de empleo sin goce de sueldo o despido del trabajo, una colilla de cheque (1) de antes del 1 de marzo y una (1) de después de esa fecha donde se muestre que se ha experimentado una disminución del ingreso debido al COVID-19.)

Status

Form ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Customer Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Customer-Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

CCWAP Eligible? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Pledge amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Reason {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Additional files {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Other verification method {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

DSS Staff {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date eligibility determined {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

English

Preliminary verification {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Due to one or more responses above, you do not meet the eligibility requirements for this program.

Please contact our office at 804-748-1100 if you have any questions or concerns.

Verification requirements not met {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Spanish

Verificación preliminar {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Due to one or more responses above, you do not meet the eligibility requirements for this program.

Please contact our office at 804-748-1100 if you have any questions or concerns.

Verification requirements not met {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

English

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spanish

Nombre {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Teléfono {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Correo Electrónico {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Dirección {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

English

Chesterfield County utility account customer number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Names of the individuals on the water/wastewater account

Individual on water/wastewater account {binding ItemNumber}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you behind in your water/wastewater payments? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Months you are requesting assistance paying water/wastewater bill {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Total amount of assistance requesting for water/wastewater bill {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please select any of the following that apply to your household {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Last date of work {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Last date support received {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How many people, including yourself, other adults and children, live in your home? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Household individuals

Household individual {binding ItemNumber}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Individual is an adult

{binding SSN_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

{binding MonthlyIncomeBeforeCOVID19_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

{binding MonthlyIncomeDuringCOVID19_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

{binding SourceOfIncome_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

{binding NameOfEmployer_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

{binding FinancialLossDueToCOVID_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spanish

Cuenta de Servicios del Condado de Chesterfield Número de Cliente {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Names of the individuals on the water/wastewater account

Nombre de las personas en la cuenta de servicios de agua y drenaje {binding ItemNumber}

Nombre {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

¿Está atrasado en los pagos de los Servicios de Agua/Drenaje? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Monto Total de Asistencia requerida para el pago de la factura de Servicios de Agua y Drenaje {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Por favor seleccione los que apliquen a su Hogar {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Último día de trabajo {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Último día que se recibió la manutención {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

¿Cuántas personas, incluyéndose usted, otros adultos, niños/bebés, viven en su hogar? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Household individuals

Household individual {binding ItemNumber}

Nombre {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Fecha de Nacimiento {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Individual is an adult

{binding NúmeroDeSeguroSocialParaParentSectionNombre_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

{binding ParentSectionNombreFirstsIngresoMensualAntesDelCOVID19_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

{binding ParentSectionNombreFirstsIngresoMensualDuranteElCOVID19_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

{binding ParentSectionNombreFirstsFuenteDeIngreso_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

{binding ParentSectionNombreFirstsNombreDelEmpleador_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

¿Experimentó pérdida financiera debido al COVID-19? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

English

Optional: Take a photo or upload a scanned copy of a recent water/wastewater bill {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Upload proof of hardship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Spanish

Opcional: Tome una foto o suba una copia escaneada de la factura más reciente de agua/drenaje. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Prueba de dificultad financiera {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

English

{binding displayValue}

Name of individual granted third party authorization {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Electronic signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Electronic signature of individual granted third party authorization {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Spanish

{binding displayValue}

Por este medio y solamente con el propósito de completar y enviar esta solicitud, le asigno autorización a un tercero. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Nombre del Tercero autorizado {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Firma electrónica del solicitante {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Firma electrónica del Tercero autorizado {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Status

Form ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Customer Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Customer-Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

CCWAP Eligible? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Pledge amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date eligibility determined {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

I have reviewed this application and confirm that the information above is correct. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}