Authorization for the Release of Personal Information to a Third Party
STATE OF NEW YORK )
) ss:
COUNTY OF ________________________________)
_________________________________________________________, being duly sworn, deposes and says:
I hereby authorize ___________________________________________________________ to act on my behalf in requesting and obtaining the following records from the Office of Temporary and Disability Assistance (OTDA) of the New York State Department of Family Assistance (State DFA), pursuant to Article 6-A of the Public Officers Law and 18 NYCRR Part 339:
1. All data pertaining to my and/or my family's application for and/or receipt of Public Assistance (PA), Medical Assistance (MA), Supplemental Nutrition Assistance Program (SNAP), Emergency Assistance to Families (EAF), Emergency Home Relief (EHR), Emergency Safety Net Assistance (ESNA), Emergency Assistance for Adults (EAA), Home Energy Assistance Program (HEAP), Supplemental Security Income (SSI), State Supplement Program (SSP), Social Security Retirement, Survivors or Disability Insurance (RSDI) benefits, social services, as defined in 18 NYCRR § 358-2.20, and child support payments.
2. All notices pertaining to my and/or my family's application for and/or receipt of the benefits, services and/or payments described in ¶ 1 above;
3. All data pertaining to all Fair Hearings, desk reviews and/or other administrative appeals that I have requested or that have been requested on my or my family's behalf.
This authorization shall remain valid and in full force and effect for one year from the date of my signature below, unless I notify DFA/OTDA in writing that I have revoked this authorization.
My Social Security number is ___________________________________.
My date of birth is ___________________________________________.
My case number is: __________________________________________.
My Client Identification Number (CIN) is: __________________________.
If the requested data includes any codes or symbols, I ask that a specific explanation of all such codes accompany all such data, pursuant to Public Officers Law § 95(1)(c) and 18 NYCRR § 339.2(c)(3)(i).
As a recipient of assistance, I cannot afford to pay for the cost of reproducing these records. Accordingly, I ask that such fees be waived in accordance with 18 NYCRR § 339.11(c).
Signature: ________________________________________________
Sworn to before me on the ____ day of
_________________________, _____________.
________________________________________
Notary Public, State of New York
