I certify that the information as submitted on my application is true and declare that to the best of my knowledge. I am the only person in my household who has applied for this service. I am aware that I can be penalized by fine and/or imprisonment for making false action taken on my application. I hereby waive my rights under the Privacy Act and Confidentiality Provision and give my consent to NashEdgecombe Economic Development, Inc. to examine any confidential information. Furthermore, I hereby grant permission and authorize any bank, employer, utility company, Fuel Company, Veterans Administration, Department of Social Services, Social Security Administration, and other public and/or private institutions to disclose to Nash Edgecombe Economic Development, Inc. full information regarding my past and/or present financial situation in order to determine whether or not I am income eligible for services.