Fair Housing Office
124 W. Washington Street, Suite B-4
Medina, Ohio 44256
Phone: 330-722-9219
Fax: 330-764-8456
Email: cheinly@medinaco.org
Dear Client:
If you need the Medina County Fair Housing Office to obtain information from or speak with an
agency or other third party for your case, please complete the release below and return to Fair
Housing Office at the above address.
GENERAL AUTHORIZATION FOR RELEASE OF INFORMATION
I/We, _________________________________, and ___________________________________
Name Name
residing at _____________________________________________________________________
Address, City, State, Zip
hereby authorize Cheryl Heinly, Coordinator and/or Katarina Devanney, Esq. of Medina County
Fair Housing to discuss with ______________________________________________ or any
Third Party
authorized representative thereof any information regarding me, my family, and my housing and
to allow for inspection and copying of any records regarding me, my family and my housing. A
copy of this release is as effective as the original.
_______________________________ __________________________________________
Name (please print)
Address
__________________________________________
City, State, Zip
________________________________ __________________
Signature
Date
R:\wp\planning\Fair Housing\forms\rev_general_release_01232018.docx
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