How do I fill out the Authorization for the Release of Information form?

The purpose of this form is to provide our agency with approval to check on various verifications. This is a required form and all adult members in the household who are 18 years and older must print their name, sign their name and put in the date of the signature on the second page. The first page is solely for your reference. The second page must be returned.

As you can see from the image below, the highlighted sections must be filled out.
Be sure to have the names in the right categories. For example:

• The first line is for the Head of Household so only the Head of Household should be in this space.
• The second line is for the co-head.
• The third line is for the spouse.
• The remainder of the lines are for all other household members over 18
• Live in aides do not need to sign this form

In this example, there are two adults in the household. One is the Head of Household (Jane Doe) and their spouse (Jim Doe). As Jane is the head of household, they would print their name in the first box, sign their name in the second box and put in the date on the third box.

Incorrect use of this form
The following reasons this form is incorrect and will need to be filled out includes the following:

• Not all adults are included on the form
• Adults are not in the correct category
• There is a missing a signature
• There is a missing printed name
• There is a date missing

Please do not submit incomplete documents of any kind. This document is a requirement. Failure to submit proper documentation may lead to program termination.