Authorization For Release Of Information Or Payments {1A004}

June 2016 1A004e MC: ME Bar Code Area FS#: Central File Maintenance P.O. BOX 12048 AUSTIN, TX 78711-2048 Vea Espa361ol al Otro Lado Dear Important Please read this page. It describes your responsibilities if you choose to authorize another party to receive case information on your behalf or obtain assistance from a private collection agency or private attorney. Below are some of the conditions that must be met for us to properly work the child support case. Failure to follow these guidelines may result in our taking appropriate action as permitted by federal regulations. All case information provided to a third party must be used for child support purposes only. All requests for information must be answered within the time frame specified. All payments must go through the Texas Child Support Disbursement Unit before being distributed to a private collection agency or private attorney. Any changes in arrears must be approved by our office. Non-cash child support must be approved by our office. We must be provided with timely notice of each order, writ or lien entered in the case by your representative. To authorize the release of information and/or child support payments to another party, complete the enclosed form. Please return the completed form to: Office of the Attorney General Central File Maintenance P.O. BOX 12048 Austin, TX 78711-2048 If you have any questions, please call 1-800-252-8014. Date: OAG Case Number: American LegalNet, Inc. www.FormsWorkFlow.com June 2016 1A004e MC: Attorney General Case #: AUTHORIZATION FOR RELEASE OF INFORMATION OR PAYMENTS Print your current name: Other names you have used: Name of the other party in the case: Names of all children on this case: OAG Case Number (10 digit number included in OAG correspondence about this case): Phone number where you can be contacted: ( ) home work cell relative or friend You do not have to redirect your payments in order to release information or records. The two choices provided below are independent of each other. By submitting this completed, signed, and dated form, I authorize and request the Office of the Attorney General (OAG) to do the following: (You must place your initials next to each item that applies.) Release information or records on my case (OAG number given above) This person is (check one) my attorney a private collection agency a representative that I am designating. Initials: Name : Phone Number: Address : City, State: Zip Code: OR Send any payments on my case (OAG number given above) to the person I am naming below. I understand that this may delay my receiving my payment. I also understand that this revokes any direct deposit authorization that I have already given to the Office of the Attorney General. This person is (check one) my attorney a private collection agency a representative that I am designating. Initials: Name: Phone Number: Address: City, State: Zip Code: I understand that this authorization automatically expires if the case is closed. I may choose to revoke this authorization at any time by submitting a completed, signed, and dated Revocation of Authorization for Release of Information or Payments. I understand that the Office of the Attorney General of Texas is not responsible for disputes between the listed party and me as a result of this arrangement. (Please note the date of your signature is required.) Signature Date (required) Address City, State, ZIP American LegalNet, Inc. www.FormsWorkFlow.com