1. My most recent Wadsworth utility bill contains a previous balance.
2. My account delinquency is attributable to an event(s) caused by the COVID-19 pandemic.
3. I understand that funds made available through the Wadsworth Utility Assistance Program are subject to restrictions and funding limitations established by the City of Wadsworth
4. I understand that funds received through the Wadsworth Utility Assistance Program are subject to the provisions of the American Rescue Plan Act, including provisions specifying:

a) Assistance is only available for expenses incurred after March 3, 2021.
b) Assistance to business customers is subject to public reporting and disclosure requirements.

What events or circumstances caused by the pandemic have made it hard to pay your utility bill?
Examples: job loss, reduction in work hours, unexpected medical bills or childcare expenses, etc.

I hereby request the following relief dollar amount for my delinquency (max of $500 per account): $

I hereby affirm or attest that the above statements are true:

Signature (Full Name):   (this will be your digital signature)

YOUR CONTACT INFORMATION

Street Address
City
State
Zip Code
Phone Number
E-Mail Address
Utility Account Number
Business Name	If this is a personal utility account, leave this blank
Please enter the numbers to the right of the box:    756481