I understand and agree that this application is voluntary, is not a guarantee of services or payment of emergency rental assistance, is not a contractual relationship, and is subject to compliance with federal, state, local, and program requirements. I have read and understand my application and the answers and documentation I provided with the application. My certifications and agreements are true and accurate to the best of my knowledge. I understand that federal, state, and local government entities and their contractors may rely on information provided in this application and that if any information is untrue in any way I may be subject to recapture of funds, repayment of funds, and all other appropriate legal remedies. I understand and agree that failure to provide necessary information or to respond to attempted contacts by entities administering this program may result in my application being withdrawn or denied. Information provided in this application and site are expressly subject to the Tennessen Warning and Privacy Act Notice provided in this application.
This site and the information provided on this site is not intended to be a substitute for professional advice, including but not limited to accounting, tax and/or legal advice, regarding your specific situation. Where specific advice is necessary or appropriate, please consult with a qualified professional in your area of need.
If I do not agree to all of these terms, I will immediately cease my use of this Site.
Limitation of Liability and Indemnification:
By using this Site, I agree to DEFEND, INDEMNIFY, RELEASE AND HOLD HARMLESS THE STATE OF MINNESOTA, MINNESOTA HOUSING FINANCE AGENCY, LOCAL GOVERNMENT ENTITIES, AND THEIR OFFICERS, DIRECTORS, EMPLOYEES, CONTRACTORS AND AGENTS (THE “RELEASED PARTIES”) FROM ANY AND ALL CLAIMS, ACTIONS, SUITS AND DEMANDS THAT RELATE TO OR ARISE OUT OF: (1) MY FTT AGATE /EMERGENCY RENTAL ASSISTANCE APPLICATION OR AN APPLICATION RELATED TO RENTAL PROPERTY; (2) ANY ACTION TAKEN OR NOT TAKEN BY THE RELEASED PARTIES IN THE ADMINISTRATION AND MANAGEMENT OF FTT AGATE / EMERGENCY RENTAL ASSISTANCE; (3) USE OR INABILITY TO USE THIS SITE OR INFORMATION AVAILABLE FROM THIS SITE; (4) LOSS OF DATA OR COMPUTER EQUIPMENT THAT RESULTED FROM THE SITE OR THE DOWNLOADING OF ANY INFORMATION OR CONTENT FROM THIS SITE; (5) TRANSACTIONS OR CONTACT BETWEEN ME AND THIRD PARTIES LINKED TO THIS SITE; (6) ANY VIOLATION OF THE TERMS OF USE AGREEMENT OR PRIVACY POLICY; AND (7) CLAIMS, ACTIONS, SUITS AND DEMANDS BROUGHT BY OTHER PERSONS OR ENTITES ARISING FROM OR RELATED TO MY USE OF THIS SITE OR INFORMATION OBTAINED FROM THIS SITE. IN NO EVENT SHALL THE RELEASED PARTIES BE LIABLE OR RESPONSIBLE FOR ANY LOSS, DIRECT, INDIRECT, PUNITIVE, SPECIAL, INCIDENTAL, OR CONSEQUENTIAL DAMAGE (INCLUDING BUT NOT LIMITED TO LOSS OF BUSINESS, REVENUE, PROFITS, USE, DATA OR OTHER ECONOMIC ADVANTAGE), ATTORNEYS’ FEES, EXPENSES OR COSTS IN THE EVENT OF SUCH CLAIMS, ACTIONS, SUITS AND DEMANDS.
Use of this site is subject to Minnesota law and user consents to exclusive jurisdiction and venue of state and federal courts in Ramsey County, Minnesota in all disputes arising out of or relating to use of this site.
Tennessen Notice - Explanation of the use of information gathered for HSPHD:
While you are receiving services from HSPHD you will be asked to give certain information about yourself, your family history, your living habits, your income and finances, and related information that is needed to assist in provision of services and/or benefits to you and your family. All of this information and any documents (case plans, assessments, etc.) will be kept in the HSPHD combined electronic record systems. Other information regarding charges for HSPHD services or payments for services may also be maintained in the HSPHD combined electronic record systems.
Minnesota law provides that this kind of information cannot be collected, used, stored, disseminated (released to others) without advising you of the manner in which this information is treated by HSPHD. You have received a copy of the HSPHD Notice of Privacy Practices that provides this information to you.
The law provides that you may refuse to give information to HSPHD. However, if you do refuse to provide information, the HSPHD staff may not know enough about you to provide the best care or coverage of that care through insurance, health plans or government programs. In some instances, if you do not provide certain information, HSPHD may not be able to provide services to you.
If you are under 18 and the nature of your services permits you to access services without parental consent, you may request in writing that no information about the services be given to your parent or guardian. You should be aware that HSPHD staff may provide information to your parent or guardian if it is determined that failure to inform a parent or guardian would seriously jeopardize your health or safety.
I understand that information about the services that I receive from HSPHD is part of HSPHD's combined electronic record system and is available for identity management and service and care coordination purposes by other HSPHD programs and other HSPHD contracted providers and health care providers. By signing below, I acknowledge that I received this form.
I understand that even if I do not sign this form, my information, including mental health data, is part of the department electronic record system and may be accessed without my permission for certain activities HSPHD is required to do by law (for example, Adult Protection Investigations, Child Protection Investigations, or Pre-Commitment Screenings).
Privacy Act Notice:
While you are receiving services from Hennepin County’s Human Services and Public Health (HSPHD) Department and it’s contracted entities, you will be asked to give certain information about yourself, your family history, your living habits, your income and finances, and related information that is needed to assist in provision of services and/or benefits to you and your family. All of this information and any documents (case plans, assessments, etc.) will be kept in the HSPHD combined electronic record systems. Other information regarding charges for HSPHD services or payments for services may also be maintained in the HSPHD HDS system.
Minnesota law provides that this kind of information cannot be collected, used, stored, disseminated (released to others) without advising you of the manner in which this information is treated by HSPHD. You have received a copy of the HSPHD Notice of Privacy Practices that provides this information to you. The law provides that you may refuse to give information to HSPHD. However, if you do refuse to provide information, the HSPHD or contracted agency staff may not know enough about you to provide the best care or coverage of that care through insurance, health plans or government programs. In some instances, if you do not provide certain information, HSPHD may not be able to provide services to you.
If you are under 18 and the nature of your services permits you to access services without parental consent, you may request in writing that no information about the services be given to your parent or guardian. You should be aware that HSPHD staff may provide information to your parent or guardian if it is determined that failure to inform a parent or guardian would seriously jeopardize your health or safety.
The services you receive from HSPHD is part of HSPHD's combined electronic record system and is available for identity management and service and care coordination purposes by other HSPHD programs and other HSPHD contracted providers and health care providers.
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