RIGHT TO NONDISCRIMINATION
This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some cases religion or political beliefs. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Additionally, program information may be made available in languages other than English. To file a complaint of discrimination, write to: U.S. Department of the Treasury, Director, Office of Civil Rights and Diversity, 1500 Pennsylvania Avenue, N.W., Washington, DC 20220; call (202) 622-1160; or send an e-mail to: crcomplaints@treasury.gov. This institution is an equal opportunity provider.

RIGHT TO CONFIDENTIALITY
We will keep your information private. It will only be used to decide which programs you may be eligible for. Any person knowingly violating any of the rules and regulations of this department shall be guilty of a misdemeanor and, upon conviction shall be sentenced to pay a fine, not exceeding one hundred ($100) dollars, or to undergo imprisonment, not exceeding six months, or both (62 P.S. section 483).

RESPONSIBILITY TO PROVIDE INFORMATION
You must give true, correct and complete information. You must help in proving the information, you give. Benefits may be denied if you fail to provide certain proof. If you are contacted by Department of Human Services (DHS) or the Office of State Inspector General, you must fully cooperate with those persons or investigators.

PRIVACY ACT STATEMENT
(i) The collection of this information, including the Social Security number (SSN) of each household member, is authorized under 42 U.S.C. § 405(c)(2)(C)(i) and 62 P.S. § 432.2(b)(3). The information will be used to determine whether your household is eligible or continues to be eligible to participate in the Emergency Rental Assistance Program. We will verify this information through computer matching programs. This information will also be used to monitor compliance with program regulations and for program management. (ii) This information may be disclosed to other federal and state agencies for official examination, and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law. (iii) failure to provide an SSN may result in the denial of Emergency Rental Assistance to each individual failing to provide an SSN. Any SSNs provided will be used and disclosed in the same manner as SSNs of eligible household members. If someone wants help getting an SSN, call 1-800-772-1213 or visit www.ssa.gov. TTY users should call 1-800-325-0778

RIGHT TO APPEAL
You have the right to ask for a hearing to appeal a decision if you believe it is unfair or incorrect, or if the provider fails to act on your application for benefits. You may file the appeal through the county agency by following the information provided on the eligibility determination notice from the ERAP agency for your county.

If you appeal, you may also request a conference with the ERAP agency before the hearing.

I understand and agree that I am responsible for any fraudulent statements made on this application, even if the application is being submitted by someone acting on my behalf. I certify that all information that has been entered is true under penalty of perjury. I understand that the information entered in this application will be kept confidential and used only to administer benefits. I understand that I may be required to work with other agencies as a condition of my approval for assistance. I agree to provide upon request any additional documentation required (i.e. pay stub, lease, recent bills, proof of unemployment, etc.) to aid in determining eligibility.

I understand and agree that I am responsible for any fraudulent statements made on this recertification, even if the recertification is being submitted by someone acting on my behalf. I certify that all information that has been entered is true under penalty of perjury. I understand that the information entered in this recertification will be kept confidential and used only to administer benefits. I understand that I may be required to work with other agencies as a condition of my approval for assistance. I agree to provide upon request any additional documentation required (i.e. pay stub, lease, recent bills, proof of unemployment, etc.) to aid in determining eligibility.