Supplemental Services Inquiry

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Client MUST upload last 30 days of gross income

"This application is being completed in connection with the receipt of Federal assistance. Program officials may verify information on this form. I am aware that deliberate misrepresentation may subject me to prosecution under applicable State and Federal statutes. I am also aware that I may not receive CSFP benefits at more than one CSFP site at the same time. Furthermore, I am aware that the information provided may be shared with other organizations to detect and prevent dual participation. I have been advised of my rights and obligations under the program. I certify that the information I have provided for my eligibility determination is correct to the best of my knowledge.

I have been advised of my rights and obligations under the program. I certify that the information I have provided for my eligibility determination is correct to the best of my knowledge. I authorize the release of information provided on this application form to other organizations administering assistance programs for use in determining my eligibility for participation in other public assistance programs and for program outreach purposes."

If yes, please initial the following statement. If not, skip to the next statement.

• I certify the information I will provide today is true and correct to the best of my knowledge.

• I understand this information will be used to screen me and my household for eligibility for public benefits and other social services and complete applications for these benefits.

• I agree to take an active part in obtaining any benefits that I decide to apply for and/or any other social services I agree to receive.

• I understand that my personal information, including my Social Security Number, address, gender, racial or ethnic background, household income, and other demographic information, will be used to determine my enrollment status for the benefits I apply for.

• I understand that if for some reason I do not complete my application today, the information I provide can be pulled up at another BDT Partnering Site at my request.

• I understand that a record of my use of these services without any personal identifying information will be used to create reports for the City of Philadelphia and the State of Pennsylvania about program eligibility, application, and enrollment of all clients served at this site in order to assess the effectiveness of the program and comply with government audits.

• I understand that upon my request, my individual information may be shared with other organizations in order to coordinate additional services on my behalf, as relevant to my case, including, but not limited to, free legal services.

• I understand that this data will not be used for tax collection purposes or be sold or used for any commercial purpose.

• I understand that I may be contacted by the City of Philadelphia to ask about my experience with the program and my interest in other social services.

Note: Once you click the “Submit” button, you will be asked to create your E-signature and click “Submit Signed Response”. Once your response has been submitted please check your email and click the verification link to finalize your signature.