Catholic Charities
 Diocese of Arlington
Letter of Acknowledgement
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I acknowledge that the individual on my lease and/or utility bill cannot be located to attend this interview with Catholic Charities for emergency financial assistance. THIS SIGNED FORM IS THE AUTHORITY by which I consent to represent this person for the purpose of exchanging personal information and discussing the bill with  Catholic Charities. In the event that assistance is given both individuals will abide by the Emergency Assistance program guideline of: Eligible clients may receive Emergency Assistance once in a 12 month period, up to 2 times in a 10 year period.

The information exchanged will be used for professional purposes only. It includes information such as name, address, telephone number, and utility account number pertaining to a person’s request or assistance for rent and/or utilities from the respective landlord and/or utility company, which has been given, as well as any other information deemed important for the delivery of services.

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