Customer Information Account Number: * First & Last Name: * Account Address Address Line 1: * Address Line 2: City & State * ZIP Code * Mailing Address (if different from Account Address): Address Line 1: Address Line 2: City & State ZIP Code Phone Number: * Email Address: * Repayment Plan Options: * 6 Month Plan (3 bi-monthly payments) 12 Month Plan (6 bi-monthly payments) 24 Month Plan (12 bi-monthly payments) By submitting this application for the Town of Round Hill VA COVID-19 Repayment Plan, I attest that I have experienced a financial hardship due to the COVID-19 Pandemic. Electronic Signature: * *By entering my name below I agree that I am signing this application electronically, and I agree that my electronic signature is the legal equivalent to my written signature. Date of Signature: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Leave this field blank
