Affirmation: I/We hereby affirm that the information and all income provided have not withheld, falsified, or otherwise misrepresented any information and my household income is at or below 100% of the Federal Poverty Limit for my family size . I /We fully understand that any and all information I/We provide will be used to determine if I/We met program qualifications. I/We I/We understand that I may be asked to provide income verification documents. I/we understand that the consequences for providing false or knowingly incomplete information in an attempt to qualify for this program may include the disqualification of application and program services.
Privacy: By using our services, I acknowledge and agree to the collection, use, and disclosure of my personal information in accordance with this organization/program requirements policy.
