As a Utility Assistance Grant applicant, I do hereby give permission to obtain and release personal information regarding my case to utility companies as deemed necessary to further assist my household in accessing funding sources. Information requested / released may include, but is not limited to, the following: 1) Services provided to or requested from the household by The Source Ministries, Inc. ; 2) Status of utility accounts, payment and consumption histories; 3) Residency and household members.
- The information provided is true and correct to the best of my knowledge and belief.
- I hereby authorize The Source Ministries, Inc. to obtain information from my utility account for the purpose of obtaining my billing history, and account balance to be used for the sole purpose of determining my eligibility for benefits of the Utility Assistance Grant . I understand that the account information obtained by my utility companies may contain personal and/or personally-identifying information.
- I understand that The Source Ministries, Inc. will not use my information provided except as needed to review this application to determine eligibility.
- I am aware that I am subject to federal prosecution for providing false or fraudulent information.
My signature indicates I have read the Release of Customer Information, Application Required Document List, and agree to abide by the terms stated.