WAP Chapter 1 (1/17)
Emergency Services Acknowledgment Form
Agency Name: _________________________________________________________________
Client Name: __________________________________________________________________
Client Address: _________________________________________________________________
I ___________________________________, hereby acknowledge the following:
I request that emergency services be performed by the
_____________________________________________________________.
(Name of agency)
I have completed the application and provided information requested to the agency for
purposes of determining eligibility and services.
The _________________________________________ is relying on the information
(Name of agency)
provided by me in providing the services.
The information by me is true, accurate and complete.
Should the information not be true, accurate or complete resulting in my household being
determined to be ineligible for assistance under the Weatherization Assistance Program, I
will be held responsible for any and all costs incurred by the
_______________________________________in performing the emergency services.
(Name of agency)
__________________________________________
Signature
__________________
Date of Signature
WARNING: SECTION 1001 OF TITLE 18 OF THE U.S. CODE MAKES IT A
CRIMINAL OFFENSE TO MAKE WILLFULLY FALSE STATEMENTS OR
MISREPRESENTATIONS TO ANY DEPARTMENT OR AGENCY OF THE U.S. TO
ANY MATTER WITHIN ITS JURISDICTION.
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