By submitting this application I certify that to the best of my knowledge I meet the program’s eligibility requirements and will notify the Hearing Aid Project immediately if my income rises above the limit. I authorize the release of information necessary to determine my eligibility from the records in possession of the Social Security Administration (SSA), Internal Revenue Service (IRS), employers, banks, utility companies and others as the need arises. It is understood that I may be held liable for repayment of any benefits or payments which are determined to have been incorrectly provided. I am authorized the Hearing Aid Project to use my personal information, such as name, date of birth, and social security number to determine eligibility in the program. This information will not be shared with any outside entities except to fulfill the requirements of the program.