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:
  • Legal Aid of Western Ohio
  • Advocates for Basic Legal Equality
  • 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.