Disaster Relief

(1) I certify that to my knowledge I am following all laws, statutes and regulations restricting U.S. persons from dealing with any individuals, entities or groups who are subject to economic sanctions imposed by the U.S., such as countries subject to embargoes or groups of individuals, such as terrorists and narcotics traffickers.
(2) I consent to the processing of my personal data contained in this Application for verification purposes and the potential disbursement of a grant from the Jack’s Family Fund. (3) I further consent to the transfer of the contents of this Application to the Fund located in Birmingham, Alabama, USA, the Jack’s Family Fund Administrator, the Jack’s Family Fund Board of Directors or Allocation Committee Members.
(4) I further certify to the Fund that the information contained in this Application is true and correct.
(5) By applying for a grant from the Fund, I agree to provide copies of the following materials if requested by the Fund: verification of the emergency hardship and financial need, photo identification for myself or any individual to whom assistance grant is made payable, household budget information, income/benefits verification, copies of past due utility bills, rent/mortgage statements, funeral invoice, medical bills, etc.