The information contained in this form is true and correct to be the best of my knowledge. Permission is
granted to the Independent Living Program to make whatever inquiries might be necessary to verify these
statements, so that my IL Coordinator will be able to determine my eligibility for services. In applying for
independent living program services, I understand there is a need to collect personal information.
I understand that consumer service record information concerning me will be kept confidential.
I understand that I have the opportunity for a timely review of any dissatisfaction with a determination made
by the Ability 1st Utah staff concerning the furnishing or denial of Independent Living Services by contacting
Sandra Curcio at 801-373-5044.
I understand that a Client Assistance Program Representative is available to act as my advisor and advocate, and that I may call toll free 1-800-662-9080 or Salt Lake 363-1347 to reach the Disability Law Center / Client Assistance Program (CAP), 205 North 400 West, Salt Lake City, UT 84103.
I understand that services in this program are provided without regard to sex, race, age, religion, color, or
national origin according to Title VI of the Civil Rights Act, and Section 504, Rehab Act of 1973, as amended.
The Independent Living Program also assures that no group of individuals will be excluded or found ineligible
on the basis of type of disability.