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Non-Residential Customer Intake Form - King George County Service Authority Arrearage Assistance

  1. Smaller B-W Seal
  2. Non-Residential Customers:*
    Check 'yes' or 'no':
  3. CARES Act assistance application may:*

    Please check each box to certify that you understand the following:

  4. The Non-Residential Applicant must certify the information below, by placing a mark in each box:
  5. Applicant's Certification:*
    Please check each box to certify the following:
  6. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  7. Leave This Blank:

  8. This field is not part of the form submission.