Rent and Utility Emergency Assistance Application & Self-Certification Form

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The United Way of the Ouachitas rent and utility emergency assistance program is being assisted with federal Community Development Block Grant CARES Act (CDBG-CV) funds from the City of Hot Springs. We are asking for your cooperation in completing this form to verify your eligibility for benefits. Please be assured that this information will be used to meet the record keeping requirements of the U.S. Department of Housing and Urban Development (HUD) Community Development Block Grant (CDBG) and the Charity Tracker shared, computerized record keeping system that captures information about people experiencing need for emergency services such as rent and utility assistance.

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CERTIFICATIONS

I certify under penalty of perjury that the above information is complete and accurate to the best of my knowledge. I understand that Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government. I further understand that any willful misstatement of information will be grounds for disqualification and barring of any future assistance. I agree to provide any additional documentation required by the program administer to determine eligibility for program assistance. I agree to provide documentation needed to assist in determining eligibility. I hereby waive my/our rights under the privacy and confidentiality provision act, and give my/our consent to the City of Hot Springs, United Way of the Ouachitas, the U.S. Department of Housing and Urban Development, Office of the Inspector General or their authorized agents to examine any information given herein.

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RELEASE OF INFORMATION

Ouachitas Assistance Network
Shared Case Management Software – Charity Tracker
RELEASE OF INFORMATION (ROI)

The Ouachitas Assistance Network, hereinafter referred to as “CharityTracker”, is a shared, computerized record keeping system that captures information about people experiencing need for emergency services, including but not limited to assistance with utility bills, medications, food, rent/mortgage payments, etc. United Way of the Ouachitas (Administering Agency) administers CharityTracker on behalf of participating agencies of the CharityTracker Assistance Network.

I understand that all information gathered about me is personal and private and that I do not have to participate in CharityTracker. I have had an opportunity to ask questions about CharityTracker and to review the basic identifying information, which is authorized by this release for the CharityTracker Assistance Network Participating Agencies to share. I also understand that information about non-confidential services provided to me by CharityTracker participating agencies may be shared with other CharityTracker Participating Agencies. This Release of Information will remain in effect for 3 years from the date noted under my signature at the bottom of this page unless I make a formal request this this Organization that I no longer wish to participate in CharityTracker.

Dependent’s Name              Relationship            Age

I authorize United Way of the Ouachitas, as a CharityTracker Participating Agency, to share my basic, identifying and non-confidential service transactions/information with other CharityTracker Participating Agencies. I authorize the use of a copy of this original to serve as an original for the purposes stated above. I further authorize United Way of the Ouachitas as a Charity Tracker Participating Agency, to share my dependent’s basic, identifying and non-confidential service transactions/information with other CharityTracker participating agencies.