As a Utility Assistance Program/Weatherization Assistance Program participant, 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 Utility Assistance Program/Weatherization Assistance Program agency; 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 bestof my knowledge and belief.
- My household incomehas been calculated to determine the household yearly income, according to pre-established agency procedures.
- I understand I may request a hearing to appeal a denial of eligibility,amount of assistance received, or a delay of service delivery.
- I authorize the Texas Department of Housing and Community Affairs and its contracted agency, BakerRipley, to solicit/verify information on my utility and/or fuel bill, both past and future, to the extent the information isused only to provide data.
- I hereby authorize the Texas Department of Housing and Community Affairs and BakerRipley, 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 the Utility Assistance Program/Weatherization Assistance Program. I understand that the account information obtained by BakerRipley may contain personal and/or personally-identifying information.
- I understand that BakerRipley willnotuse my information provided exceptas needed to review this application to determine eligibility.
- I am aware that Iam subject to federal prosecution for providing falseor fraudulent information.
- I understand that BakerRipley 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.