Department Of Health And Human Services Record Release Authorization {NHJB-2171-FP}

THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) DEPARTMENT OF HEALTH AND HUMAN SERVICES RECORD RELEASE AUTHORIZATION To: (RSA 170-B:18, VI and 463:5, VI and 464-A:4, V) Department of Health and Human Services and all its divisions I hereby authorize the release of any child or adult abuse and/or neglect record that you may find concerning me to the (name of court) (address of court) 1. Name Mailing address 2. Also known by following names (example: maiden name) , at 3. 4. Date of birth List other states where you have resided as an adult and when I understand that the information disclosed and provided by you under this request and release authorization is intended for use by the above named court, in conjunction with the above referenced matter and subject to any confidentiality requirements applicable to such legal proceeding. Date Signature State of This instrument was acknowledged before me on , County of by Date Person Signing Above Signature of Notarial Officer / Title My Commission Expires Affix Seal, if any The court requires that the search be conducted and the information be provided as specified above. PER ORDER OF THE COURT, Date NHJB-2171-FP (08/31/2009) (formerly AOC-232-003) Register of Probate / Regional Court Clerk Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com