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Tuesday, 06 June 2017 21:03

Benevolance Application

  
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.