I/We understand that the information on this questionnaire is being utilized to access the complex issues of homelessness and help determine the need for shelters within the county.

I/We also acknowledge that the information on this questionnaire will be used in conjunction with other agencies to more adequately utilize all services required.

I/We also understand that false statements or information can hinder Cherokee County in it's attempts to provide quality service to residents who need shelter.

I/We hereby certify that the information on this questionnaire to be utilized by the Cherokee County Homeless and Shelter Survey is true and accurate to the best of my/our knowledge and belief.

___________________________        __________________                 Signature of Respondent               Date of Application

___________________________         __________________              Signature of Spouse                       Date of Application