"Concern for Personal Safety Privacy Form - Maryland Office of Home Energy Programs" - Maryland

Concern for Personal Safety Privacy Form - Maryland Office of Home Energy Programs is a legal document that was released by the Maryland Department of Human Services - a government authority operating within Maryland.

Form Details:

  • Released on July 1, 2018;
  • The latest edition currently provided by the Maryland Department of Human Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Maryland Department of Human Services.

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RETURN THIS FORM TO:
MARYLAND OFFICE OF HOME ENERGY PROGRAMS
CONCERN FOR PERSONAL SAFETY PRIVACY FORM
Instructions : Applicants who are not able to provide a delivery address on their application for energy assistance, due to safety
concerns must complete this form. Verification is required; no self-affirmations are accepted. Only one of the boxes
must be completed.
Applicant:
Client ID:
I,
, am not able to provide my address or location due to safety concerns. I request that OHEP
waives this requirement and my application be processed without this information. I have been asked to provide verification to
support my claim. I have provided the verification below. (Only one box needs to be completed).
Records:
I submit one of the following:
Law Enforcement Records
Medical/Treatment Records
Child Protective Services Records
Court Records
Social Service Records
Other (Specify):
Authorization/Verification by a Third Party:
I authorize
to complete the verification below and to provide it to the Office of Home Energy Programs
for the purpose of verifying my good cause.
Applicant Signature:
Date:
This statement is submitted by:
Name & Title:
Address:
Organization:
Phone:
I am: (Check One)
A Domestic Violence Service Provider
A Legal Representative
A Medical, Psychological or Social Service Provider
An Acquaintance/Friend/Relative/Neighbor of the Claimant
A Law Enforcement Professional
Other (Specify):
A County Children and Youth Representative
I have knowledge of the claimant’s experience with and/or steps to escape domestic violence and submit this statement to verify that
compliance with the OHEP program requirement to provide living address may place the claimant and/or household or family members
at risk of further domestic violence; make it more difficult for the claimant and/or household or family members to escape domestic
violence; or unfairly penalize the claimant and/or household or family members who is or has been victimized by domestic violence.
Third Party Signature:
Date:
OFFICE USE ONLY:
Date and Time Received:
Reviewed & Approved:
Worker’s Signature
Date
OHEP PRIVACY (REV 7/18)
RETURN THIS FORM TO:
MARYLAND OFFICE OF HOME ENERGY PROGRAMS
CONCERN FOR PERSONAL SAFETY PRIVACY FORM
Instructions : Applicants who are not able to provide a delivery address on their application for energy assistance, due to safety
concerns must complete this form. Verification is required; no self-affirmations are accepted. Only one of the boxes
must be completed.
Applicant:
Client ID:
I,
, am not able to provide my address or location due to safety concerns. I request that OHEP
waives this requirement and my application be processed without this information. I have been asked to provide verification to
support my claim. I have provided the verification below. (Only one box needs to be completed).
Records:
I submit one of the following:
Law Enforcement Records
Medical/Treatment Records
Child Protective Services Records
Court Records
Social Service Records
Other (Specify):
Authorization/Verification by a Third Party:
I authorize
to complete the verification below and to provide it to the Office of Home Energy Programs
for the purpose of verifying my good cause.
Applicant Signature:
Date:
This statement is submitted by:
Name & Title:
Address:
Organization:
Phone:
I am: (Check One)
A Domestic Violence Service Provider
A Legal Representative
A Medical, Psychological or Social Service Provider
An Acquaintance/Friend/Relative/Neighbor of the Claimant
A Law Enforcement Professional
Other (Specify):
A County Children and Youth Representative
I have knowledge of the claimant’s experience with and/or steps to escape domestic violence and submit this statement to verify that
compliance with the OHEP program requirement to provide living address may place the claimant and/or household or family members
at risk of further domestic violence; make it more difficult for the claimant and/or household or family members to escape domestic
violence; or unfairly penalize the claimant and/or household or family members who is or has been victimized by domestic violence.
Third Party Signature:
Date:
OFFICE USE ONLY:
Date and Time Received:
Reviewed & Approved:
Worker’s Signature
Date
OHEP PRIVACY (REV 7/18)