I understand that I have the right to appeal any decision regarding this application which I consider improper, and also any delay in decision or delivery of services.

I understand that I must help establish my eligibility by providing as much information as I can about my circumstances.

I authorize the contracted agency to release information relating to my application for LIHEAP to my Energy Supplier(s) to determine eligibility. I give permission to the Arkansas Energy Office (AEO) to use information provided on this form for purposes of research, evaluation and analysis of the program.

I understand that my utility service provider will have no control over the data disclosed pursuant to this consent and will not be responsible for monitoring or taking any steps to ensure that the LIHEAP office maintains the confidentiality of the data or uses the data as I have authorized.

I understand that no person may be denied assistance on the basis of race, color, sex, age, handicap, religion, national origin, or political belief.

I understand that submitting this form authorizes the agency to make any investigation concerning me or any household member and/or use a copy as a release of information for securing information needed to determine my eligibility for services.

I understand that if I receive assistance to which I am not entitled as a result of withholding information or knowingly providing false or fraudulent information regarding my circumstances, I must repay the cost of any assistance and may face penalty of criminal prosecution.

The information given on this application is true to the best of my knowledge and belief. I understand that this form is signed subject to penalties for perjury.