KC's Cause Release

KC's Cause Inc.

Consent For Mutual Exchange/Release of Information

KC's Cause is a charitable foundation that was formed by the Caplinger Family with the sole purpose of keeping KC Caplinger's generous and kind spirit alive by helping others. KC's Cause will work to provide support to families and individuals that have or are dealing with financial, emotional or physical hardships through the same kindness and giving that KC displayed while he was alive.

General Information
Full Name*

PrefixFirst NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Requesters Date of Birth*
How Did You Hear About KC's Cause?*
If requesting rental/Utility Assistance, Have You Reached Out To Your Local Trustee's Office?
Who Did You Speak With At The Trustee's Office?
Did The Trustee Grant You Any Assistance and if so How Much?
If Denied Assistance, What Was Their Reasoning?
Where Are You Currently Employed?
Full or Part Time
Monthly Bring Home Pay. (You May Be Asked For Proof Of Income)
Total Number Of People In Your Household.
Please List name, Age and Monthly Income For Each Household Member.
Date

MonthDayYear
Date
In a narrative of no more than 250 words,Please describe request
Description of Request*

0/500

Certification
1. Submitting this form authorizes KC's Cause LLC to share certain personal information collected about you and/or your family in order to coordinate services and assistance, and to reduce the paperwork necessary for you and/or your family to receive services and assistance.

2. With the exception of certain limited circumstances, it is the policy of KC's Cause LLC not to release information about individual or family assistance, or other personal information obtained, without the written consent of the individual or family. Therefore, we need your written consent to share this information, as requested to assist you and/or your family with the services that are being requested.
Signature (Please type your name)*
I understand this authorization will expire when the request has been filled by KC's Cause.
Date Completed

MonthDayYear
Signature (Please type your name)
I understand that I may refuse to sign this authorization, but my refusal to sign may affect the ability of the providers to provide me with the necessary services. If I refuse to sign this authorization, services not dependent upon this release may be available.
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