By typing my name below: I grant permission to Savannah Tech, to give and share and make use of the following information about me with their affiliates which include employees, subcontractors, Community Based Organization partners and vendors (including the Gateway Screening Service), in order to assist me in determining my eligibility for benefits offered by the City of Savannah, the State of Georgia, the federal government and/or other non-profit organizations and other related benefits included in the Gateway software.
Such information includes but is not limited to, the following:
I give this permission so that Savannah Tech, their partners and their employees, affiliates, subcontractors and partners can pre-screen me and my dependent(s) for and assist me and my dependent(s) in obtaining public and other benefits using the Gateway screening Software.
I give permission to local or state governmental benefits-determining agencies to discuss my application progress with Savannah Tech and its affiliates (as defined above) in order to determine my application status and to provide me with records and information concerning me, including but not limited to whether benefits were approved or denied, that may be under the custody and control of such local or state governmental benefits-determining agencies.
I understand that Savannah Tech and its affiliates (as defined above) shall keep any information confidential and will not reveal or give it to anyone else without my permission. I also understand that Savannah Tech shall make reasonable efforts to ensure that its affiliates (as defined above) keep any information confidential and will not reveal or give it to anyone else without my permission. I understand and agree that Savannah Tech and its affiliates (as defined above) may use this information for research and reporting purposes. However, my personal information will not be revealed except as required by the lawful, or requirement of a governmental agency or court of competent jurisdiction, or as otherwise required by law.
I further certify that any information I provide will be true and accurate to the best of my knowledge.
By signing my name below I also certify that I have read this consent form or someone has read it to me. This consent will be effective unless and until I end it by way of a written statement signed by me.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.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. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: Complaint Form, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: email@example.com. This institution is an equal opportunity provider. Federal Law and U.S. Department of Agriculture policy prohibit discrimination on the basis of race, color, national origin, sex, age, disability. To file a complaint of discrimination, write to USDA, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, DC 20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay). USDA is an equal opportunity provider and employer.