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Please read and complete this application in its entirety before certifying its accuracy and submitting.
(Found on your Monthly Statement)
Please enter their names and requested information below:
If selected YES- the next question is required.
If selected YES - the next question is required.
If $100 does not cover the entire amount due, customer must pay the difference in order to avoid potential discontinuation of services
(check as many as you want):
Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.
I understand that information provided in this application is confidential in regard to my City of Archdale utility account, but that portions may become public record as documentation for federal funding.
I further acknowledge that my eligibility for utility funding assistance is based on having a qualifying annual family income level AND having been negatively impacted by the COVID-19 pandemic. I understand that failure to provide complete and accurate information may be the basis for rejection of my application. My signature below attests that all information provided is accurate to the best of my knowledge.
This field is not part of the form submission.
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