General Assistance Application (Page 8 of 8) in pdf

General Assistance Application Page 8

Authorization to Release Information

I hereby authorize Jackson County General Assistance to release the information I have provided (including

use of social security numbers) for the purpose of checking the accuracy of that information by contacting any

local, state or federal government agency, private business, church, firm, agency, any financial institution,

YWCA DV/SA Resource Centers of Jackson & Clinton Counties and

______________________________________________.

I also authorize Jackson County General Assistance to inform vendors to whom assistance would be paid on my

behalf, including my landlord, whether my application has been approved or denied.

In addition, I hereby authorize all of the previously named agencies and persons as well as all persons (doctors,

employers, Department of Human Services (DHS), other Relief or Veterans Affairs Offices, banks, etc.) to

release confidential information to Jackson County General Assistance if it deems such information necessary.

This release is valid for one (1) year from the date of signature.

I solemnly swear that the statements I have made are true and correct to the best of my knowledge and belief.

Do Not Sign!

Signature must be notarized or signed in the presence of the General Assistance Director or Intake Officer!

______________________________________________________________________________________________________

(Signature of Applicant)

Date

_______________________________________________________________________________________________________

(Signature of Co-Applicant)

Date

_______________________________________________________________________________________________________

(Signature of Director or Intake Officer)

Date

STATE OF IOWA

COUNTY OF ______________________

Signed and sworn before me, on this ________ day of _________________________, 20_____,

by ___________________________________________________________________________

Name(s) of Persons

Notarized by: _____________________________________________________, Notary Public

Print Name: ___________________________________

(Seal)

My commission expires: _______________________

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General Assistance Application Page 8