COUNTY OF SACRAMENTO DEPARTMENT OF HUMAN ASSISTANCE
WTW 1007_34F Page 1 of 1
Case Number: __________________________
Date: __________________________________
Case Name: ____________________________
Worker Name: __________________________
Worker Phone Number: ___________________
Worker Number: _________________________
WTW Authorization for Release of Information
The information requested below is needed to verify client’s earnings and hours of
participation in approved Welfare-to-Work activities. It is being requested from The
Work Number, Los Rios Community College District, Sierra College, SETA or other
agencies listed below:
___________________________________________________________________
___________________________________________________________________
I, ______________________________________, hereby authorize you to release to the
Sacramento County Department of Human Assistance specific information requested by
this agency concerning:
( ) my employment, including employer name, dates of employment, wages and
benefits paid, and hours worked per pay period or month.
( ) my enrollment in school, including class list, class schedule, class start and stop
dates, and drop date, if applicable.
This authorization is valid for one year from the date signed.
I understand and agree that a photocopy or facsimile (fax) of this form with my signature
shall be considered as valid as the original.
I certify that I have read (or had read to me) and understand the contents of this form.
Signature:______________________________________ Date:___________________
