"Authorization to Release Information"

This "Authorization to Release Information" is a document issued by the U.S. Department of the Interior - Bureau of Indian Affairs specifically for United States residents with its latest version released on January 1, 2018.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the U.S. Department of the Interior - Bureau of Indian Affairs.

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BUREAU OF INDIAN AFFAIRS
HOUSING IMPROVEMENT PROGRAM (HIP)
AUTHORIZATION TO RELEASE INFORMATION
To Whom It May Concern:
I/We hereby authorize you to release to
for verification purposes, any and all information concerning the following:
Employment history dates, title, income, hours worked, etc.
Banking, savings, and IIM accounts of record.
General Assistance income.
Any other information requested as deemed necessary to verify our application.
This information is for the CONFIDENTIAL use of
, in
evaluating your application for Housing Improvement Program (HIP) financial assistance.
A photographic or carbon copy of this authorization (being a photographic or carbon copy of the
signature (s) of the undersigned) may be deemed to be equivalent of the original and may be used
as a duplicate original.
FULL NAME:
PARENT/GUARDIAN
(SIGNATURE)
(IF REQUIRED - SIGNATURE)
FULL NAME:
SOCIAL SECURITY NUMBER:
ADDRESS:
PHONE NUMBER:
SUBSCRIBED AND SWORN TO ME, THE UNDERSIGNED NOTARY PUBLIC
THIS
DAY OF
, 20
.
NOTARY PUBLIC
MY COMMISSION EXPIRES:
2018 ver
BUREAU OF INDIAN AFFAIRS
HOUSING IMPROVEMENT PROGRAM (HIP)
AUTHORIZATION TO RELEASE INFORMATION
To Whom It May Concern:
I/We hereby authorize you to release to
for verification purposes, any and all information concerning the following:
Employment history dates, title, income, hours worked, etc.
Banking, savings, and IIM accounts of record.
General Assistance income.
Any other information requested as deemed necessary to verify our application.
This information is for the CONFIDENTIAL use of
, in
evaluating your application for Housing Improvement Program (HIP) financial assistance.
A photographic or carbon copy of this authorization (being a photographic or carbon copy of the
signature (s) of the undersigned) may be deemed to be equivalent of the original and may be used
as a duplicate original.
FULL NAME:
PARENT/GUARDIAN
(SIGNATURE)
(IF REQUIRED - SIGNATURE)
FULL NAME:
SOCIAL SECURITY NUMBER:
ADDRESS:
PHONE NUMBER:
SUBSCRIBED AND SWORN TO ME, THE UNDERSIGNED NOTARY PUBLIC
THIS
DAY OF
, 20
.
NOTARY PUBLIC
MY COMMISSION EXPIRES:
2018 ver
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