List names of EVERYONE (children and adults) living in your household AND the amount of income for each. If not employed, please state why (unless they are under 18). List assistance currently being received for each as well.
I give consent for United Way/Faith Fund to obtain and/or release written and/or verbal confidential information regarding my status/involvements to the agencies/persons listed below. The type of information obtained and/or released will be for the purpose of eligibility determination, implementing, monitoring a plan or service. Types of information obtained and/or released may include, but not be limited to, income information, status with a particular agency, service rendered, problem situations, general progress, etc.
Indiana Family & Social Service Admin.
Department of Child Services
Community and Family Services
Local Food Banks
Law enforcement agencies
Any agency, institution, company or person that may have given assistance or in which I have had resources available to me.
I further agree that I will hold harmless any person, agency, copany or institution who gives information to the United Way/Faith Fund about me.
This consent form is valid for three years from date signed and may be revoked by me, in writing, at any time. All information will be kept confidential.