I have carefully read this form and hereby certify that all the information given is true and correct to the best of my knowledge. I hereby authorize the release of any and all information given to this application or verbally to East End Providers for the purposes of verification or service. I hereby hold East End Providers and/or its members harmless for any action arising out of this request for assistance or for the assistance provided. I understand that if I/we applied in more than one place or to more than one organization, all applications may be discarded or marked void.

***All information will be verified***