Aid Application, Income, Expense and Debt Verfication_Compassionate Caregivers Fund - Flipbook - Page 3
I certify that the information provided in this Aid application is true and correct to the best of my knowledge. Any
intentional misrepresentation of information contained in this application will result in forfeiting this and anyfuture
grant application. I authorize the Committee administering this program to verify my employment earnings
records, bank accounts, and any other assets needed to process my Aid application.
I understand that the Compassionate Caregivers Fund Aid Review and Approval Committee will take
reasonable measures to protect my privacy. However, I understand that my anonymity cannot be guaranteed.
I understand that funds may not be available at this time, and that my application does not guarantee
approval of funds.
Date:
Signature:
For Committee Use Only
Fund Aid Approval:
Yes
No
Reason:
Amount Approved: $
Make Check Payable To:
