City Utility COVID-19 Exemption Application

Date

Customer Name

Service Address

Address or Location

Account-CID#

Phone Number

To qualify for exemption, you must be experiencing a hardship related to COVID-19.

Please identify your hardship

To qualify for exemption, you must also already have applied for financial assistance related to your outstanding utilities. Please identify at least two agencies that you have submitted applications to and the last date of contact you had with them.

Resource 1 contacted

Other resource 1 contacted

Date resource 1 contacted

Resource 2 contacted

Other resource 2 contacted

Date resource 2 contacted

I certify that:

My annual income is less than $99,000 for calendar year 2020 or no more than $198,000 if filing a joint return;
I have a COVID-19 related hardship that made me unable to pay my bills;
I commit to making at least partial payments towards my utility bill; and
I have already applied for financial assistance related to my outstanding utility bill to at least two agencies.

It is possible for damage to water lines or personal property to occur when water is shut off at a location and subsequently turned back on. By making your payment or entering in to a repayment plan, and your continued use of the City of Bloomington’s water service, you hereby acknowledge the possibility of damage and agree to waive any and all possible claims caused by the shut off or restarting of your water service, and agree to continue to make your current and future payments as they are due.

This program will allow a one-time grace period that will expire 4 months from the date of this agreement, not to exceed April 30, 2022.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the City of Bloomington and myself. By signing and submitting this Exemption Application, I, under penalty of perjury, state that the information provided in this Exemption Application is true. I further understand that the information I have provided in this Exemption Application may be audited and that if any false information results from the audit, my Exemption will be denied and/or repealed and I may also personally face other penalties or legal actions.

If you have any questions regarding your account or payment arrangement, please call 309-434-2426 (Option 4) or email us at cashiers@cityblm.org and include your account number and both the first and last name on the account.