As a Community Utility Assistance participant of Trinity Temple COGIC, I do hereby give permission to obtain and release personal information regarding my case to other agencies as deemed necessary to further assist my household in accessing services and to funding sources for reporting purposes. Information requested / released may include, but is not limited to, the following: 1) Services provided to or requested from the household by Trinty Temple COGIC; 2) Status on utility accounts, payment and consumption histories; 3) Proof of income, residency, and household members;4) Employment;5) Education and 6) Proof of identity and citizenship for all household members. The information provided is true and correct to the best of my knowledge and belief. My household income has been calculated to determine the household yearly income, according to pre-established guidelines and procedures. I understand I may request a meeting with Bishop Benjamin Stephen, III and Trinity Temple COGIC Board of Directors to appeal a denial of eligibility,amount of assistance received, or a delay of service delivery. I authorize the Trinity Temple COGIC and its organization's representative, to solicit/verify information on my utility or rent bill, both past and future, to the extent the information isused only to provide data. I hereby authorize Trinty Temple COGIC to obtain online access to my utility account information for the purpose of obtaining my 12-month billing history, 12-month payment history, and account balance to be used for the sole purpose of determining my eligibility for benefits in Trinity Temple COGIC Utility Assistance Program. I understand that the account information obtained by Trinity Temple COGIC may contain personal and/or personally-identifying information. I understand that Trinity Temple COGIC may use my personal contact information provided to offer me additional information about its organization. However, will only use my utility, housing and income information as needed to review this application to determine eligibility. I am aware that I am subject to federal prosecution for providing false or fraudulent information. I understand that Trinity Temple COGIC will use the U.S. Department of Homeland Security (DHS)/ Systematic Alien Verification for Entitlements (SAVE) to verify status of non- U.S. born naturalized household members, citizens or permanent residents who provide the following documentation: Permanent Resident Card, Certificate of Naturalization, Certificate of U.S. Citizenship, Refugee Travel Document, Arrival/Departure Record, or Re-entry Permit. My signature indicates I have read the Release of Customer Information, Application Required Document List, received a copy of the Customer Acknowledgement and agree to abide by the terms stated.