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Seattle CiviForm
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Personal information entered on this form is subject to Washington Public Records Act, and may be subject to disclosure to a third-party requestor. At the City of Seattle, we are committed to protecting your privacy and will ensure that any disclosures are done according to law. To learn more about how this information is managed please see our Privacy Statement: http://www.seattle.gov/tech/initiatives/privacy
By checking this box, I am aware that my information is subject to review and verification and that other documentation may be required. I certify that my information is accurate and complete. I agree to provide proof of eligibility if requested and to notify the City of Seattle of any eligibility changes. False or misleading information may result in removal from the program and possible prosecution. I understand that submitting this waitlist application does not guarantee eligibility or enrollment in any programs.
Fresh Bucks are a household benefit and enrollment is limited to one per household. I confirm that I am submitting one application for my household and that no one else from my household has applied for or is already enrolled in the Fresh Bucks program
The City of Seattle may use the data you provide to research and evaluate outcomes associated with the Fresh Bucks program. The work product of the research will not include identifiable information. *
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