Consent to Disclosure of Information

CONSENT TO THE DISCLOSURE OF INFORMATION TO THE TOWNSHIP TRUSTEE

(Print Name Above)

Case Number

(type in case number above)

Residing at

(type in current address above)

Consent to the disclosure of the following information to ________ the investigator

(investigator name above)

of township assistance for ________ Township

(type township above)

_________ County, of Indiana.

(type county above)

Information that will verify my:

1. Countable Income

2. Countable Assets

3. Wasted Resources

4. Relatives capable of providing assistance

5. Past or present employment

6. Pending claims or causes of action

7. A medical condition if relevant to work or workfare requirements

8. Any other information required by law

This information may be used only in connection with:

1. My Township Assistance Application From __________, Township

(type what township above)

__________ County, Indiana.

(type what county above)

2. My application for public assistance from the Division

of Family and Children county offices and the Office of

Medicaid Policy and Planning.

3. Others (if any).

Signature of Applicant

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Use your mouse or finger to draw your signature above

Date Signed

Signature of Other Adult

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Date Signed

Signature of Other Adult

[clear]

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Date Signed

This consent form expires 180 days after signing.

ACKNOWLEDGMENT AND PLEDGE OF CONFIDENTIALITY BY THE TOWNSHIP

The undersigned township trustee or employee acknowledges that he/she may, in the course of employment, have access to certain personal information and that such information is to be treated as confidential, and is to be released and exchanged only with agencies related to the undersigned employment by the township in reviewing and investigating this application or as otherwise provided by law.

Trustee Or Employee

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Use your mouse or finger to draw your signature above

Date Signed