Bill Payment Assistance Request

To request assistance, submit this form to verify your income falls within the qualifying levels for COVID-19 Bill Payment Assistance.

Name

First Last

HR Co-op Account Number:

Phone

Email

Address

Street Address Address Line 2 City State ZIP Code

Income Verification(Required)

By checking this box I certify that during the COVID-19 pandemic which began in March 2020, our total household income from all sources, for all members of the household, has fallen below the limits shown in the table above, and that we are requesting assistance paying our HR Co-op bills.

I hereby verify the above information to be true and complete. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.

CAPTCHA