Public Benefits Pre-Screening Form

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:

• My name and social security number, address,and related personal information;
• The name and social security number and related personal information of any of my dependents or household members;
• Whether or not I, or any of my dependents now receive any form of public benefits;
• If so, how much I or my dependent(s) receive and when I or my dependent started getting them;
• If I, or my dependent(s), was not approved to receive benefits, the reason for the denial or why no action was taken;
• If I or my dependent(s) stopped receiving benefits, when the benefits stopped and why; and
• Any information necessary to complete the application for a type of benefits for myself, a dependent, or member of my household fully and accurately.

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.