The Beautiful Sound
of Giving

I acknowledge that the information in this application is correct to the best of my knowledge. I understand the information I submit to ACNC Cares concerning my annual income, household size, family resources, insurance, medical history and all financial information is subject to verification by ACNC Cares and/ or their agents. This verification will be done by phone, letter, email or credit check. I understand that if I knowingly omit or submit false information, I will be denied consideration for assistance at any point during the process, and I will be required to reimburse the ACNC Cares program for any benefits I may have already received.

I hereby grant to ACNC the irrevocable and unrestricted right to use, publish, and reproduce, in whole or in part, and in full or as subsequently edited, any photographs, video, audio, written or audio-visual representations of me taken by employees, agents, or contractors of Starkey, for library publications, electronic reproductions, commercial, promotional, or training materials, web sites, or any other purpose and in any manner or medium.

Include proof of income for all in the household, from all sources. Provide copies of six of your most recent bank statements (all accounts, for all household members and all pages of each statement). Provide documentation for any item to which you responded “Yes” above.