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Client/DHRD AGREEMENT

Applicant’s Responsibilities

 

I understand that:

 

  1. The answer(s) I give on this form will be used to help determine my eligibility for any assistance applied for through DHRD. (GA, LIHEAP, TANF, WIOA, Mentoring, CCBG).
  2. The amount of my grant depends on the number of eligible people in my household. If I report that an eligible person has left or had income, which makes him/her ineligible, the amount of my grant is subject to change.
  3. The amount of my grant also depends on the amount of income received by me and others covered by my grant. If the income I report is more than the grant allowance, I will be denied for the month.
  4. I am required to sign a Release of Confidential Information Form in order to assist my worker in establishing my eligibility.
  5. I am aware of the Tribal, Federal, State of Montana laws that provide for a fine and/or imprisonment of any person(s) who attempt to receive, or receives assistance to which he/she is not entitled.
  6. DHRD has the right to cross-reference this application with other requests for assistance, to verify household members, claimed income, place of residence, etc.
  7. DHRD may deny assistance based on the information provided on DHRD applications until the applicant provides additional information.
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FEDERAL LAW GOVERNING FRAUD

I UNDERSTAND THAT:

Whoever, in any matter within the jurisdiction of any Department or Agency of the United States, knowingly and willfully, conceals or covers up by any trick, scheme or device, a material fact, or makes false, fictitious, or fraudulent statements or representation or makes any false writing or document, knowing the same to contain any false, fictitious statement or entry, shall be fined not more than $10,000 or imprisoned not more than 5 years or both.

 

 

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FEDERAL LAW GOVERNING FRAUD

I/We agree to supply all necessary information about my/our resources and income and to notify DHRD when my/our situation changes. I/We authorize DHRD to obtain information necessary to establish my/our eligibility for assistance from the appropriate Agencies and that this information shall be kept CONFIDENTIAL.  I/We further agree that this information may be released for the purposes of investigation of fraud.

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