Authorized Representative

City of Nashua
Welfare Department Division of Public Health & Community Services 18 Mulberry Street, Nashua, N.H. 03060
PH: (603) 589-4555 FAX: (603) 594-3643
Authorized Representative Form:
I/ We authorize (NAME of AUTHORIZED REPRESENTATIVE) to act on my/our behalf and obtain application and materials to apply for general assistance through the City of Nashua Welfare Department. I/ we authorize the City of Nashua Welfare Department to release information as requested to the individual listed above regarding my/our general assistance application and eligibility determination.
Print Name of Authorized Representative
Print Applicant Name
Applicant Signature

Clear
Print Co-Applicant Name
Co Applicant Signature

Clear
Applicant Signature Date Co-Applicant Signature Date

*This authorized representation is in effect for as long as the applicant is currently seeking assistance from the City of Nashua Welfare Office or up to six (6) months after assistance has ended, or until said authorization is discontinued in writing by the applicant.
Should be Empty:

City of Nashua