I further certify that all information provided herein is true to the best of my knowledge. I am aware that this information is subject to review and verification and I may have to provide documents to support it. I am aware that I may be denied assistance if I am found ineligible or if I do not meet the program requirements. I am aware that I may be prosecuted if I have knowingly given false information in order to receive assistance. I have been notified of my right to appeal any denial of service or assistance for which I may be eligible.

I am aware that this information is subject to review and verification and I may have to provide documents to support it. I hereby waive my rights under the privacy act and confidentiality provisions and give my consent to Choanoke Area Development Association of NC, Inc. (CADA) to examine any confidential information. Further, I hereby grant permission and authorize any bank, employer, utility company, fuel company, Veterans Administration, local Departments of Social Services, Social Security Administration, and other public and/or private institutions to disclose to CADA full information regarding my past and/or present financial situation in order to determine whether or not I am income eligible for services. I allow release of information contained herein for purposes of verification.