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Authorization For Release Of Information - Pennsylvania Department Of Public Welfare

CASE IDENTIFICATION

CAO NAME AND ADDRESS

RECORD NUMBER

CAT

CSLD

DIST

RECORD NAME

DATE

AUTHORIZATION FOR RELEASE OF INFORMATION

NAME

SOCIAL SECURITY NUMBER

ADDRESS

ZIP CODE

I hereby authorize and request the disclosure to the County Assistance Office any information

concerning the age, residence, citizenship, employment, applications for employment, education and

training activities, income, resources and any additional information involving eligibility for public

assistance for myself and/or those individuals on whose behalf public assistance benefits are paid to

me. It is understood that the information obtained will be used only for purposes directly related to the

eligibility of individuals in the public assistance case.

WITNESS

SIGNATURE

DATE

TITLE

SIGNATURE

DATE

WITNESS

SIGNATURE OF REPRESENTATIVE

DATE

APPLYING ON BEHALF OF CLIENT(S)

TITLE

ORIGINAL CASE RECORD FILE

RECORD COPY

FORM RETENTION PERIOD:

ACTIVE CASE - RETAIN UNTIL NEW FORM IS SIGNED.

CLOSED CASE - RETAIN 4 YEARS FROM MONTH OF CASE CLOSURE

PA 4 (SG) 3/13

Authorization For Release Of Information - Pennsylvania Department Of Public Welfare