Release of Information Fillable Form

Please complete the following form. The completed form will be emailed to the email you have specified. Please upload the form in your TANF application or in the upload portal.

Please contact XXXXX for questions or concerns regarding this process.

Adult 1

Name(Required)

First Last Middle Initial

Social Security #(Required)

Date of Birth(Required)

Home or Primary Phone #(Required)

Mailing Address(Required)

Address Line 1

Mailing City, State and Zip Code(Required)

City State ZIP Code

Adult 2

Name

First Last Middle Initial

Social Security #

Date of Birth

Home or Primary Phone #

Mailing Address

Address Line 1

Mailing City, State and Zip Code

City State ZIP Code

Children

Child Name 1

First Last Middle Initial

Child Name 2

First Last Middle Initial

Child Name 3

First Last Middle Initial

Child Name 4

First Last Middle Initial

Child Name 5

First Last Middle Initial

Child Name 6

First Last Middle Initial

In order to protect your private information the completed PDF form will be encrypted with a password. Please type a password you can remember.

Password(Required)

The completed PDF form will be emailed to you please provide an email address below.

Email(Required)

Applicant Signature

Applicant Date Signed

Co-Applicant Signature

Co-Applicant Date Signed