Authorization to Release

1.The information provided is true and correct to the best of my knowledge and belief.

2.I understand that my gross household income is annualized at the time of application according to pre-established agency rules and procedures in order to receive assistance.

3.I understand that I may request a hearing to appeal a denial of eligibility, amount of assistance received, or a delay in service delivery.

4.I authorize the Texas Department of Housing and Community Affairs and West Texas Opportunities, Inc. To solicit/verify information including employment verification needed to provide assistance.

5.I am an applicant of West Texas Opportunities, Inc. I hereby give my permission to release and verify all information requested and understand that it will be kept in strict confidence to be used for program purposes only. I understand that photocopy of this release is as valid as the original and may be used to obtain employment information or verify other data including educational and student records. I authorize the Texas Department of Housing and Community Affairs and West Texas Opportunities, Inc. to solicit/verify information on my utility and/or fuel bills, both past and future, to the extent the information is used only to provide data.

6.I understand that if I change utility companies I must notify the case worker within 5 business days of my new utility company and account number with the name on the account. If I do not notify West Texas Opportunities, Inc. of my new utility company I will lose any payments due. When the information is provided, any remaining assistance may be reinstated.

7.I read and understand the energy conservation tips. 

8.I completed a Needs Assessment and referrals will be made if needed.

9.I read the provided information about the weatherization program and given the opportunity to apply.

10.I UNDERSTAND THAT I AM SUBJECT TO PROSECUTON FOR PROVIDING FALSE OR FRAUDULENT INFORMATION ON THIS APPLICATION.

 

 

 

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