2. My account with the Wadsworth Utilities is currently past due as a direct result of the COVID-19 pandemic:
(please state specifically how COVID-19 led to delinquency ie. Lost job of you or family member, medical treatment, additional daycare costs or other expenses etc):
3. I wish to be considered for the Wadsworth Utility Assistance Program which could eliminate or reduce my past due balance with Wadsworth Utilities.
4. I understand that the relief is:
5. I hereby request the following relief dollar amount for my delinquency (max of $500 per account):
I hereby affirm or attest that that the above statements are true:
Signature (Full Name): (this will be your digital signature)
YOUR CONTACT INFORMATION