The applicant(s) certifies that all information in this application is given for the purpouse of obtaining assistance under the Repair Affair program from the Balch Springs Neighborhood Services Department and is true and complete to the best of the applicant's knowledge and belief. Any misstatement or falsification of information shall be grounds for revocation or termination of assistance. Applicant understands that this application does not guarantee that any requests for assistance will be granted. 

Title 18, Section 1001 of the U.S. Code stated that any person who knowingly and willingly makes or uses a document or writing contating any false, fictitious, or fraudulent statement in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than 10,000 or imprisoned for not more than five years, or both. 

I hereby, authorize the City of Balch Springs Neighborhood Services Department or its designated agents to obtain and receive all records and information pertaining to eligibility for the Repair Affair Program, including employment, income, credit, residency, and banking information formal all persons, companies, or firms holding or having access to such information. This authorization hereby gives the City of Balch Springs Neighborhood Services Department the right to request all information that we and or could obtain from any persons, company, firm or any matter referenced above. I (WE) agree to have no claim for defamation, violation of privacy, or otherwise against any person or firm, or corporation by any reason of any statement of information released by them to the City of Balch Springs Neighborhood Services Department for purposes of the program. The term of this authorization shall commence on the date of the signature and be in force foe a period of six(6)months.