Effective Date: 



Updated: 5/2003


To provide staff a form to verify TANF and/or Food Stamp benefit information to other entities, such as public housing, WIC, etc.


When to Prepare

Staff completes the form at the client's request.

Number of Copies

Original only.


Give the completed form to the client in person or via mail or fax.


There is no retention requirement for this form.

Detailed Instructions

After the client signs and dates the release section and indicates which programs and months they are authorizing release of information for, staff

  • enters the name and address of the requestor;
  • enters the date and advisor name;
  • enters the office address and telephone number;
  • enters the case number(s) and the benefit amount information requested; and
  • signs and dates the form.

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