Coronavirus Relief Fund Customer Attestation Form

Account Number*  (Please use the following format: 12345-001)  

Business/Entity Name   

Account Name*  

Phone Number

Check all applicable cause(s) of hardship experienced as a result of the COVID-19 pandemic   Please describe Your COVID-Pandemic-Related Hardship    

Customer Certification and Attestation

By my signature below, I desire to receive any assistance to which I am legally entitled under the Coronavirus Relief Fund through the federal CARES Act and its specifications. I certify and attest that the reason(s) 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 Northern Virginia Electric Cooperative to verify records as necessary to verify my eligibility for assistance. 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. I certify that I have 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 Northern Virginia Electric Cooperative to verify information concerning my need for assistance. This form will be retained by the Cooperative and may be subject to audit by state or federal government agencies.

Attestation

By my signature below, 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 Cooperative to verify records as necessary to verify my eligibility for assistance. I declare to the best of my knowledge that I am the only person who has applied for/on behalf of the non-residential account, including its successors (if any), at the address shown on this form, and that I am not a government account holder.  I certify that I have 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 the Cooperative to which I am applying to verify information concerning my need for assistance. This form will be retained by the Cooperative and may be subject to audit by state or federal government agencies.

Signature* Your typed name will serve as your signature  

Job Title 

By checking this box, I agree that my electronic signature will have the same legal effect as a handwritten signature pursuant to the Virginia Uniform Electronic Transaction Act.