Application Certification
The information provided by me to establish my eligibility is true and accurate to the best of my knowledge and it is not provided with the intent to
defraud. I hereby acknowledge that the information relating to determine my eligibility requires verification and/or documentation and by my signature,
I authorize others to release such information as may be required for the determination of my eligibility. Furthermore, I authorize Helping Hands to
share personal information concerning my transactions with other emergency service providers for the purpose of official business only. I understand
that in all other respects the confidentiality of my personal information will be safeguarded. I understand that Helping Hands has the right to refuse
service to me and my family.