I hereby authorize the release of information in order to receive the assistance I am requesting.
I further certify the information I have stated is true and correct and that all income is reported.
I understand this agency may verify the information on the application and the deliberate misrepresentation of information may subject me to denial of assistance.
I give permission to this agency to discuss my case with other agencies, individuals and any others deemed necessary to verify the application information and/or identify additional sources of assistance.
I understand that all information will remain as private as possible within these entities.
I have read, understand and agree to the policies above the regarding the Release of Information.
