By signing below,
I (we) hereby authorize the investigation of all statements contained in this application and all
associated supporting documents submitted by me (us).
Further, I (we) declare, subject
to penalties of perjury, that the
information contained in this
application as well as in any supporting documents, papers,
or interviews have been examined and to the best of my (our)
knowledge and belief are true and accurate. I (we) understand that the filing of false statements may be prosecuted in civil or criminal proceedings under the State or Federal Law. I
(we) further understand that the completion of this application in no
way constitutes approval by Park County
Administration or it's assigned agents nor obligates
funds in any way.
I, we, certify
that I have fully disclosed all of my financial resources and they are true and correct. I understand that any
misrepresentation of my financial
resources and/or circumstances can result in disqualification from the program.
I (we) attest
that to the best of my (our) knowledge and belief all information submitted
in connection with this application shall be accurate and complete. I (we) understand that the submission of inaccurate or fraudulent information may be grounds for denial or
recapture of a grant, and may be
punishable by criminal, civil or administrative penalties. I (we)
understand that any information I (we) give may be investigated and
I (we) certify that the property for which I am applying for assistance
is my current primary residence.
each applicant agrees, by signature and submission of this application:
A) To allow Park County Government (County)
to share this information with other non-profit organizations, and
agencies associated with the County.
B) To allow other non-profit agencies
to share their information with the County
and its agents.
any federal, state, or local
government agency or authority that has or is providing
funding to the County to share its information with County.
Any information shared with the State
pursuant to the foregoing provision will be considered the personal/financial
information of the applicant and will be treated
as such under Colorado Freedom
of Information Act.
This is an equal opportunity program. State or Federal law
prohibits discrimination on the basis of race, color, religious creed, age,
marital status, national origin, ancestry, sex, gender identity or expression,
mental retardation, mental disability, or physical disability. Persons with
disabilities who require alternate means for communication of program
information (Braille, large print, audiotape, etc.) should contact program
administrators at firstname.lastname@example.org or 719-247-5452
with inquiries for assistance.