AUTHORIZATION TO RELEASE INFORMATION
MEMBER NAME: ______________________________________________________
SOCIAL SECURITY NUMBER: ___________________________________________
ADDRESS: _____________________________________________________________
_______________________________________________________________________
I, ________________________________________, do hereby authorize the
WEST VIRGINIA CONSOLIDATED PUBLIC RETIREMENT BOARD and its staff,
representatives, and counsel to release information pertaining to my state retirement
account and any available benefits and options to _______________________________,
and/or his/her legal representatives or attorneys, in conjunction with ________________.
By executing this Authorization for the limited purposes stated herein, I hereby waive
any right of privacy or confidentiality which I might otherwise have to the information
regarding my retirement account.
A photocopy of this Authorization is to have the same force and effect as the
original, and this Authorization is to remain in full force and effect until expressly
revoked by me in writing.
Dated this _____day of ________________, 20___.
______________________________________
(Signature)
STATE OF _________________;
COUNTY OF _______________, to-wit:
I, __________________________, a Notary Public in and for the state of
___________, do hereby certify that ___________________________ did sign this
document before me on this the ______day of _____________, 20___.
______________________________________
Notary Public
My Commission Expires: _________________
S:/forms/Authorization to Release Info
