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I certify that all information given in this form is true, complete, and accurate.
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I released this organization for any responsibility in case of accident, illness, or injury.
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I permit all information provided to the agency can be shared with WGB's partners in determining my household’s eligibility.
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I understand that all items provided by this program is intended for the members of my household.
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I understand that I must not sell or exchange any items I receive.
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I understand that what I receive is based on donations. Quantity and brands are based on inventory. Special requests can not be accomodated.
- I understand that the information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.