I hereby give consent and authorize the following agencies to reciprocate information to and with:
Chippewa-Luce-Mackinac Community Action Agency
524 Ashmun St, Sault Ste Marie, MI 49783
Phone: (906) 632-3363 Fax: (906) 632-4255
The purpose of this Consent 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 1 year after the original date of signature.