Authorization for the Release of Information/Privacy Act Notice
Head of Household
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Social Security Number (if any) of Head of Household
Spouse
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Family Member over age 18
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Family Member over age 18
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Family Member over age 18
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Family Member over age 18
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Family Member over age 18
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Family Member over age 18
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
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Should be Empty: