Authorization For Release Of Information - Pennsylvania Department Of Public Welfare

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CASE IDENTIFICATION
CAO NAME AND ADDRESS
CO
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

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