Information to be disclosed and time period of information requested (Identify specifically the information to be used/disclosed such as welfare records, lien records, inspection records, etc. If information to be used or disclosed includes mental health, drug and alcohol, or HIV-related information, please complete section of this form that relates to that information):

This information is to be disclosed to:

I authorize the use/disclosure of individual information as described below from the records of:

Reason for disclosure: Rental/Utility assistance

a)This authorization may be revoked at any time by writing to the individual/organization identified in section 1 except to the extent that information has already been disclosed. If information has already been disclosed in reliance on this authorization, revoking it will only prevent future disclosure. b)WYO HELP and its health and human services programs will not condition treatment, payment, enrollment or eligibility on the provision of this authorization. c)information (except drug and alcohol information) disclosed pursuant to this authorization may be subject to redisclosure by the individual/organization identified in section A.2 below and is no longer protected by federal privacy regulations. d)The Department, its programs, services, employees, officers, and contractors are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized. e)I may refuse to sign this authorization.

This authorization expires on: December 31, 2022