Legal Clinic Application 12.20.2022

CSBG Legal Clinic - Driver's License Reinstatement Application
To complete this application, you will need to provide scans or photos of the following documents:
- Driver's license or state-issued photo ID
- Social security card for applicant (a valid social security number is required for all other household members)
- Proof of household income for the past 30 days, for all household members age 18 and over
Are you or a member of your household currently employed by Miami Valley Community Action Partnership?*

I am an employee of Miami Valley Community Action Partnership.A member of my household is currently employed by Miami Valley Community Action Partnership.No.
Number of Adults in Household
Number of Minors in Household
Applicant Driver's License or State ID Number *
Including yourself, how many people are in your household?*

Explanation of Need
Have you ever had a valid Ohio driver's license?*

YesNo
When was the last time you had a valid Ohio driver's license?*

MonthDayYear
Date
Why do you urgently need to get your driver's license reinstated?*

Attestation of Accuracy and Authorization for Information Exchange
By signing this authorization,
- I certify that all the information I have provided on this application is true and accurate to the best of my knowledge.
- I grant permission for the sharing of information which is to be used to determine eligibility for participation in the Community Services Block Grant (CSBG) or other agency programs under the umbrella of Community Action as operated by Miami Valley Community Action Partnership for either myself or my household members.
- I understand this release will terminate upon my request so in writing.
- I understand that all information obtained in association with this release will be held in strict confidence by the receipient.
- I further direct that information shared resulting from my signature not be further disclosed without my specific written authorization.
- I further declare that I understand and permit an information exchange strictly for disclosure purposes related to Miami Valley Community Action Partnership programming.
- I hereby give permission to release and/or secure information from the following organizations for the purpose of securing services I have requested:
  - Ohio Bureau of Motor Vehicles
  - Legal Aid of Western Ohio
  - Advocates for Basic Legal Equality
  - Any court, collection agency, or other organization necessary to help restore my driver's license
  - Other organizations that I have listed below
- I certify that this statement is true and correct to the best of my knowledge, and I authorize the release of any or all information necessary for verification process.
- I authorize the Ohio Department of Development, Office of Community Services, or its designated representatives to access public assistance, Social Security, employment, or other records neeeded to verify any statements I have made in this application.
- I understand that this application for assistance does not establish me as a client of the MVCAP Legal Clinic and that the purpose of this application and submission of documents is solely to determine eligibility for MVCAP's services.
- I understand that acceptance of my application/case is not guaranteed.
- I understand that I am not a client of MVCAP or MVCAP Legal Clinic until I am expressly notified as such.
- I understand that additional information or documentation may be requested by MVCAP to determine eligibility for services.
I hereby give permission to release and/or secure information from the following organizations for the purpose of securing services I have requested:
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: