CONSENT FOR RELEASE OF INFORMATION

CONSENT FOR RELEASE OF INFORMATION
Arkansas Department of Human Services
CONSENT FOR RELEASE OF INFORMATION

Warren Housing Authority Person or Agency
801 West Central Street
Warren, AR 71671
This is your authority to release the request of TEA/Food Stamps information rewarding First Name Last Name to the Arkansas Department of Human Services or authorized representative listed below**
Date

Month Day Year
Signature

Clear
Witness
Signature of Spouse/Relative if Applicable and Relationship

Clear
Should be Empty: