airtable.com Open in urlscan Pro
52.20.132.148  Public Scan

Form analysis
0 forms found in the DOM

Text Content

ALERT

Lorem ipsum
Okay





RESOURCE NAVIGATION AUTHORIZATION FORM



Name

Phone number

Email

Authorization confirmation *
I acknowledge and understand that checking this box authorizes the resource
navigators working with the Hill District Consensus Group and/or the Pittsburgh
Hispanic Development Corporation to assist with resource navigation and complete
applications on my behalf. I hereby certify that, to the best of my knowledge,
any eligibility information shared with a Resource Navigator is true, correct,
and complete.  I agree to report any changes in circumstances immediately to a
Resource Navigator.  I understand I have a right to request a Department of
Public Welfare Fair Hearing consistent with the Title XX notice at
https://titlexx.renthelppgh.org.  I also understand that have the right to file
a grievance to complain about how my case was handled, is being handled, or if I
disagree with a decision about whether I am eligible for Resource Navigation
services at http://grievance.renthelppgh.org. I understand that documentation of
all eligibility factors may be requested to determine eligibility correctly or
for auditing purposes.  I understand that services will be provided at no cost
to me.  I understand and consent to the closing of my case upon the completion
of services by the Resource Navigator.  

Additional authorized persons
If there are additional people who you want the Resource Navigator to be able
speak with, please list them and their phone numbers and or email addresses
below






Never submit passwords through this form.
Report malicious form