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Residential Customer Intake Form - King George County Service Authority Arrearage Assistance

  1. Smaller B-W Seal
  2. Applicable Cause of Economic Hardship:**
    Please mark 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):
  3. CARES Act assistance application may:*
    Please check each box to certify that you understand the following:
  4. The Residential Applicant must certify the information below, by placing a mark in each box:
  5. Applicant's Certification:*
    Please check each box to certify the following:
  6. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  7. Leave This Blank:

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