City of Wadsworth: CARES Act Form

I   (First Name)   (Last Name) hereby state as follows

 

I hereby affirm or attest that 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
Please enter the numbers to the right of the box:    690997