Oregon Department of Justice
Ellen F. Rosenblum, Attorney General
Frederick M. Boss, Deputy Attorney General
Division of Child Support
1162 COURT ST NE
SALEM OR 97301
Telephone: 503-947-4388
FAX: 503-947-2578
Oregonchildsupport.gov
Authorization to Disclose Support Records
I, (print or type name), Social Security number
, Date of Birth (mm/dd/yyyy), authorize
the disclosure and release of my confidential child and/or spousal support payment records to:
(name of person or entity)
(email address or fax number)
Mark the one that applies:
[ ] This authorization covers my support records in Oregon CSP case # .
I authorize the release of the payment history for the last twelve full months to the person or
entity listed above.
[ ] This authorization covers my support records in all cases found using the information provided
above. I authorize the release of the payment history for the last twelve full months to the person
or entity listed above.
This authorization shall remain in effect for six months from the date of signature unless
revoked in writing by me prior to that date to the person or entity named above or directly to the
Oregon Child Support Program.
Signature ___________________________________________
Print Name
Date
