I give permission to Vivify Community Charities, Inc to acquire additional information and to securely share information with other organizations for the purposes of providing services to assist my household. I am hereby making an application for assistance and recognize that any willful misrepresentation of the information on this form is subject to a penalty of law.
I recognize that Vivify Community Charities generally does not make payments directly to client applicants. Therefore, I am also authorizing Vivify Community Charities, Inc to contact my utility company, landlord, or complex for information and to make payments directly to my utility company, landlord, or complex.