CONSENT FOR RELEASE OF INFORMATION

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

St Francis Community Housing
Forrest City, Arkansas 72335
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

MonthDayYear
Signature

Clear
Witness
Signature of Spouse/Relative if Applicable and Relationship

Clear
Should be Empty: