Income, Non-Cash Benefits, Health Insurance Information:
Please fill a section out for each person in the household that has income.
If there are any 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):
Consent to Disclose Release of Information
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 Dislcose/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 1 year from the date this release is signed.