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2. First Name
3. Last Name
5. Village of Freeport Electric Account
7. Street Address
9. City
10. State
11. Zip
13. Did You (and/or spouse):

    1. Continue to work thru the pandemic
    2. Get laid off from work
    3. Have your hours reduced at work
    4. Stop working due to emergency shut down
15. Did you Receive:*

    1. Help from the Department of Social Services
    2. HEAP
    3. Good Neighbor Fund Assistance
    4. Unemployement (including$600/week federal payment)
    5. Stimulus Check
17. Did your household income:*

    1. Remain the Same
    2. Decrease-if yes, Explain below
19. If Decrease is selected,how significantly?
21. Have you made payments on your Freeport Electric account since March 1, 2020?*

    1. Yes - how many?
    2. No - please explain why
23. If Yes - Indicate how many. If No- Please explai why?
25. If necessary, you may be required to provide proof of any of the above questions. This proof would only be used by Freeport Electric to determine eligibility and terms of SPA and/or Shut-off. By signing below, I attest that due to the COVID-19 state of emergency, which began on March 7, 2020, I have experienced a change in financial circumstances.
27. Customer Signature*
28. Date
    Date
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30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit Submit and Print

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