CLIENT INFORMATION RELEASE

Note: Each person (including authorized representatives, guardians, and adult household members) must submit their own copy of this form.

Name

I give my permission to the Office of Temporary Assistance to receive information from and to discuss my case with the following agencies, individuals, or their designated representatives:

Agencies, individuals or their designated representatives

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This release is time limited and the information will be used only for professional purposes by people providing services and its confidential nature will be respected.

Signature

First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Effective Dates