Fraud Statement: The information above is, to the best of my knowledge, true and complete. I understand that priority in providing assistance will be given to those households with the lowest income and greatest need, i.e., those households in which the elderly, disabled, medically needy, or children under the age of 5 reside. I authorize the agency to make benefit payments directly to my energy supplier. I am aware that after I have provided all the information requested, if I am applying for crisis assistance, the agency has 48 hours; 18 hours if my situation is life threatening, to approve or deny my application, and, if I am applying for Home Energy Assistance, the agency has 45 days to approve or deny my application. I am also aware that if I am not approved or denied within the time allowed, or not apprvoed for the correct amount, I have a right to an appeals hearing.
Acceptance of Application to Mid Florida Community Services, Inc.: I certify that the guidelines have been explained to me and that I waive the provisions for the privacy act to allow MFCS to verify income eligibility. I further certify that all information on this application is true and correct.