If there are new births, please send a copy of proof of birth and social security card. Head of Household - Please complete the following section (for statistical purposes only):
I certify that only the people listed above will occupy the unit. I understand that providing false information will result in denial or termination of benefits.
I hereby give consent and authorize the following agencies to reciprocate information to and with:
Chippewa - Luce - Mackinac Community Action Agency 524 Ashmun Street, Sault Ste. Marie, MI 49783
Phone: (906) 632-3363 Fax: (906) 632-4255
The purpose of this consent is to Disclose/Release of Information is to assist with housing/homeless related issues including behavioral. I (we) understand that I (we) cannot be denied assistance if we refuse to sign. To revoke this consent, it must be in writing prior to the expiration date of one year from the date this release is signed.