Complete Other Household Member(s) Information Below:
I hereby attest that the information I have provided on this intake form and any attachments is true and accurate to the best of my knowledge. I understand that this information is subject to verification and I realize the deliberate falsification or misrepresentation may result in the rejection of my application, and may subject me to prosecution under applicable State and Federal statues. I hereby give my consent to information contained on this form to be discussed and/or released to concerned social service agencies or other entities in order to make an accurate determination of my eligibility and complete the delivery of assistance to my household. I have been notified of my right to appeal any denial of service or assistance for which I may be eligible and the procedure for appeal. By this consent, I shall hold CPCA harmless for any liability that I may incur as a result of any disclosure made with the bounds of my consent and authorization.
Application Expiration Date is 30 days from signature date below.