PENNSYLVANIA DEPARTMENT OF HUMAN SERVICES

Statement of Entitlement
By entering my full name in the space provided below and transmitting this form electronically, I state, I am the person whom I represent myself to be herein, and I affirm the information within this web application is complete and accurate and made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities. In addition, I acknowledge that misstating my identity or assuming the identity of another person may subject me to misdemeanor or felony criminal penalties for identity theft pursuant to 18 Pa.C.S. §4120 or other sections of the Pennsylvania Crimes Code.

Sign by typing your full name below.