• The information provided is true and correct to the best of my knowledge and belief.
•  My household income has been calculated to determine the household yearly income, according to pre-established agency procedures.
• I understand that submission of my application does not guarantee assistance.
• I understand if approved funds will be directly paid to the utility company.
• I authorize the Violet New Birth Ministries, to solicit/verify information on my utility bills, both past and future, to the extent the information is used only to provide data.
• I understand that Violet New Birth Ministries will not use my information provided except as needed to review this application to determine eligibility.
• I am aware that Iam subject to federal prosecution for providing false or fraudulent information.

My signature indicates I have read and agree to the terms stated.

I certify that the above information is true and correct to the best of my knowledge and belief. I understand that the information will be verified to an extent; and, that I am subject to prosecution for providing false or fraudulent information.

I AM AWARE THAT I AM SUBJECT TO PROSECUTION FOR PROVIDING FALSE OR FRAUDULENT INFORMATION.

Please upload clear photos of the following documents for ALL household members, including ALL adults and children living in the same address.