Form H "Consent for the Release of Information" - Northwest Territories, Canada

ADVERTISEMENT
ADVERTISEMENT

Download Form H "Consent for the Release of Information" - Northwest Territories, Canada

Download PDF

Fill PDF online

Rate (4.5 / 5) 20 votes
Case Number:
Income Assistance
Form H – Consent for the
Release of Information
Last Name
Applicant Information
First Name
Date of Birth
/
/
Telephone
(YY/MM/DD)
Current Mailing Address
Community
, NT
Postal Code
Type of Information Requested for Release
All
Rent
Income Assistance
Utilities
Income
Other
If other, please specify:
 
 
 
 
 
 
Release Information to
Last Name
First Name
Position
Company/Agency
I hereby consent to the Department of Education, Culture and Employment, Government of Northwest Territories, to
Declaration
release the information referred to above. No other Company/Agency will be given this information without my further
written consent. This form is valid for one year.
Applicant Signature
Date
/
/
(YY/MM/DD)
This information is being collected under the authority of the Access to Information and Protection of Privacy (ATIPP) Act, section 41.(1)(g) and
the Northwest Territories Social Assistance Act and Income Assistance Regulations. The privacy provisions of the ATIPP Act protect information,
and all applicants have the right to examine and request correction of his or her records and to request a review by the Information and Privacy
Commissioner. If you have any questions about the collection of information, contact the Department of Education, Culture and Employment,
Box 1320, Yellowknife, NT X1A 2L9 or call 1-866-973-7252 or 867-767-9355
Case Number:
Income Assistance
Form H – Consent for the
Release of Information
Last Name
Applicant Information
First Name
Date of Birth
/
/
Telephone
(YY/MM/DD)
Current Mailing Address
Community
, NT
Postal Code
Type of Information Requested for Release
All
Rent
Income Assistance
Utilities
Income
Other
If other, please specify:
 
 
 
 
 
 
Release Information to
Last Name
First Name
Position
Company/Agency
I hereby consent to the Department of Education, Culture and Employment, Government of Northwest Territories, to
Declaration
release the information referred to above. No other Company/Agency will be given this information without my further
written consent. This form is valid for one year.
Applicant Signature
Date
/
/
(YY/MM/DD)
This information is being collected under the authority of the Access to Information and Protection of Privacy (ATIPP) Act, section 41.(1)(g) and
the Northwest Territories Social Assistance Act and Income Assistance Regulations. The privacy provisions of the ATIPP Act protect information,
and all applicants have the right to examine and request correction of his or her records and to request a review by the Information and Privacy
Commissioner. If you have any questions about the collection of information, contact the Department of Education, Culture and Employment,
Box 1320, Yellowknife, NT X1A 2L9 or call 1-866-973-7252 or 867-767-9355