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Washougal Utility Assistance Program

2. COVID-19 Utility Relief Program for Single Family Residents and Small Businesses Application
   This is a temporary program that has been established to provide financial relief by absorbing utility customers past due amounts (greater than 30 days) for recipients impacted by the COVID-19 outbreak. Applications can be submitted by an Eligible Residential Customer or Eligible Small Business (50 or fewer employees) impacted financially by this national, state and local emergency.

   This is a temporary program that has been established to provide financial relief by absorbing utility customers past due amounts (greater than 30 days) for recipients impacted by the COVID-19 outbreak. Applications can be submitted by an Eligible Residential Customer or Eligible Small Business (50 or fewer employees) impacted financially by this national, state and local emergency.

4. I have been negatively impacted by the COVID-19 pandemic.*

   1. Yes
   2. No

6. Section 1

8. I am the *

   1. Property owner
   2. Renting tenant

10. Please note: the status of a renting tenants' application will be shared with the property landlord. Renting tenants will be advised of the status of an application submitted by the property landlord.

12. Name:*

14. Phone Number:*

16. Service Address:*

18. Number of people in household:*

20. Email Address*

22. Please be ready to provide the following information either by uploading the files below or emailing directly to jennifer.forsberg@cityofwashougal.us.
    Driver’s license, passport, or other photo ID

    Driver’s license, passport, or other photo ID

24. Upload supporting documentation here.
    If you need more than 3 upload fields, please email your documentation directly to jennifer.forsberg@cityofwashougal.us

    If you need more than 3 upload fields, please email your documentation directly to jennifer.forsberg@cityofwashougal.us

26. Upload 1

27. Upload 2

28. Upload 3

30. Section 2
    Complete only if you are applying as a Single-Family Resident

    Complete only if you are applying as a Single-Family Resident

32. 1. Do you work or have a job?

    1. Yes
    2. No

34. If YES please enter your pay per month.*

36. 2. Do you have other household members with income who live with you?

    1. Yes
    2. No

38. If YES, how many?*

40. Do they work?*

    1. Yes
    2. No

42. If YES, what is their take-home pay per month?*

44. 3. Do you and/or other household members receive unemployment, Social Security, or workers’ compensation

    1. Yes
    2. No

46. If YES, which one(s)?*

48. Amount per month?*

50. 4. Do you or other household members receive money from any other source, including but not limited to rental income, dividends, veterans benefits, pensions/retirement income, etc.?

    1. Yes
    2. No

52. Amount per month? Include total from all sources.*

54. Please note: the status of a renting tenants' application will be shared with the property landlord. Renting tenants will be advised of the status of an application submitted by the property landlord.

56. Please be ready to provide the following information either by uploading the files below or emailing directly to jennifer.forsberg@cityofwashougal.us.
    1. Pay stubs for the past three months for both you and your spouse (if applicable) 2. Other documentation showing income from numbers 3 & 4 above

    1. Pay stubs for the past three months for both you and your spouse (if applicable) 2. Other documentation showing income from numbers 3 & 4 above

58. Upload supporting documentation here.
    If you need more than 3 upload fields, please email your documentation directly to jennifer.forsberg@cityofwashougal.us

    If you need more than 3 upload fields, please email your documentation directly to jennifer.forsberg@cityofwashougal.us

60. Upload 1

61. Upload 2

62. Upload 3

64. AFFIDAVIT:*

    I swear under the penalty of perjury of the laws of the State of Washington, that I understand the questions of this application and that all of the statements on this application are true. Any false statement, including omission, of information on this form is subject to a gross misdemeanor.

65. Date*
    Date

67. Questions?
    Although city offices remain closed per the Governor’s Safe Start plan, staff is available to assist customers with applications by phone or online. Please contact the Utilities Staff at 360-835-8501.

    Although city offices remain closed per the Governor’s Safe Start plan, staff is available to assist customers with applications by phone or online. Please contact the Utilities Staff at 360-835-8501.

Leave This Blank:


69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

* indicates a required field