I understand that it is against the law to make false statements, and that I am subject to prosecution if I do.
▪ I authorize the release of information from my rental/utility vendor(s) to the
Humanity In Progress (HIP) and further authorize the HIP to communicate with my vendor(s) on
my behalf as it relates to the Assistance Program.
▪ I understand that my household can submit only "one" application for Assistance per program year and that the home I am applying for is the home I
I understand that HIP will confidentially use this information to provide improved
services and acquire other grants. I certify that the information given above is true and complete to the best of my knowledge. I am signing knowing I am the designated representative of my whole household and this is the only application submitted for the members of this household. I understand that providing false or misleading information regarding anyone in my household is fraudulent and may be subject to criminal penalties.
By signing, I certify that I have read and understand the above agreement.