I hereby certify that all information provided by me is true and correct to the best of my knowledge. I also authorize the Elder Financial Safety Center at The Senior Source to contact my utility provider to obtain information regarding my account if necessary.

I understand that the Elder Financial Safety Center at The Senior Source provides utility assistance once a year, and if wanted, I can participate in other programs and services of the Center that can better my financial situation.

I give permission to The Senior Source to collect and enter my personal and household information into the MAAClink computer system to complete an Atmos Energy gas pledge. I understand the MAACLink system is shared with and used by authorized agencies in my community to assist me with my needs.