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