Please be aware of the following before you complete an application.  

Completing the application will include "signing" to say that you understand these rights and responsibilities:

 APPLICANT’S RIGHTS AND RESPONSIBILITIES 

**PLEASE BE SURE THAT YOU HAVE INDICATED YOUR AGREEMENT IN THE SPACE PROVIDED BELOW FOR SIGNATURE OF THE APPLICANT OR AUTHORIZED  REPRESENTATIVE. FAILURE TO SIGN AND DATE THE APPLICATION WILL DELAY THE PROCESSING OF YOUR CMAC APPLICATION FOR EMERGENCY  ASSISTANCE.

• I understand I must help establish my eligibility by providing as much information as I can about my circumstances. 

• I authorize the contracted agency to release information relating to my  application with CMAC/Salvation Army to my utility supplier to  determine eligibility. 

• I understand that my utility service provider will have no control over the data disclosed pursuant to this consent and will not be  responsible for monitoring or taking any steps to ensure that CMAC/Salvation Army maintains the confidentiality of the data or uses the  data as authorized by you. 

• I declare that all members of my household are legal residents of the United States.

• I understand that no person may be denied assistance based on race, color, sex, age, handicap, religion, national origin, or political belief.

• I understand that my signature on this application authorizes the agency to make any investigation concerning me or any household  member and/or use a copy as a release of information for securing information needed to determine my eligibility for assistance. 

• I understand that if I receive assistance, to which I am not entitled, as a result of withholding information or knowingly providing false or  fraudulent information regarding my circumstances, I must repay the cost of any assistance and face the penalty of criminal prosecution.

 • I understand to be assisted with a utility bill I must have a current disconnect notice attached, and it must be verified  through the utility company. 

• I UNDERSTAND THAT CMAC/SALVATION ARMY (Hamburg Unit) HAS LIMITED FUNDING AND CANNOT APPROVE EVERY  APPLICATION AND/OR AMOUNT REQUESTED. 

*I UNDERSTAND THAT I CAN ONLY RECEIVE ASSISTANCE FROM CMAC/SA ONE TIME PER YEAR REGARDLESS OF THE AMOUNT OF MY GRANT. 

The information given on this application is true to the best of my knowledge and belief. I understand it is signed subject to penalties for perjury.