Application for COVID-19 Business Utility Account Relief Name of Business*Address of Utility* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant Name* First Last Applicant Email* Applicant Phone*Describe the nature of your business' impact relevant to COVID-19.*(IE - Sales variance from previous month or same period year over year.)Was your business forced to close as a result of the Governor’s Stay At Home mandate?*YesNoSelf Certification* By checking this box, as the business owner I self attest that this business had an adverse financial impact resulting from COVID-19. As such I am requesting that the City of Youngsville provide a credit to my water and sewer account equal to the March and April charge as prescribed by Resolution 2020-13.Signed:*Please type your signature.NameThis field is for validation purposes and should be left unchanged.