AUTHORIZATION TO RELEASE INFORMATION
TO WHOM IT MAY CONCERN:
RE:
You are hereby authorized to furnish and release to the Morris County Adjuster,
or any representative of his/her, any and all information which may be requested
relative to one or more of the following but not limited thereto;
A) Employment, past or present, benefits which include but are not
limited to Hospitalization Insurance, Pension, Stock options, etc.
B) Bank Accounts, Checking, Savings, C.D.’s, Loans, etc.
C) Ownership of any property, business whether sole ownership or
otherwise.
D) Other
This information will be used to determine the subject’s eligibility and extent of
services provided by this agency. Under the New Jersey Statutes Annotated
(N.J.S.A.30:4-27 et seq.) this information will remain confidential and cannot be
released without consent by the subject, his/her attorney or by Court Order of the
Superior court of New Jersey.
The undersigned has received a copy of this authorization.
Dated:_______________________ __________________________
(Signature)
__________________________
(Witness)
