DMA-5044
Consent for Release of Information
I, _______________________________, hereby give my permission for the source listed
(person signing form below)
below to release the specified information regarding ____________________________
(applicant/recipient)
to the________________________ County Department of Social Services.
I understand that I may revoke my permission at any time. This consent form is valid for
one year from the date of my signature below, unless otherwise stipulated. I understand
that this information is confidential and will be used solely for the purpose of determining
and/or re-determining my eligibility for assistance.
Source:
Information Requested
Signature of individual authorizing disclosure If not applicant/recipient, specify:
[ ] Parent of minor
[ ] *Guardian
[ ] * POA
[ ] *Authorized representative
* Attach copy of supporting documentation
__________________________________
Date
__________________________________ ___________________________
Witness Date
__________________________________ ___________________________
2
nd
Witness (only if signed by an “X”) Date
