Revocation Of Authorization For Release Of Information-Payments {1A005}

MC: ME <F023> Bar Code Area <F019> FS#: <F019> Central File Maintenance P.O. BOX 12048 AUSTIN, TX 78711-2048 Release of Information revocation letter <F004> <F005> <F006> <F007> <F008> <F009> <F010> Date: <F002> OAG Case Number: <F003> Si necesita asistencia para leer esta carta, por favor llame al número: <F021> Dear <F025>: We currently have in our files your authorization to release information and/or child support payments to another party. To revoke this authorization, please 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 our offices at 1-800-252-8014 November 2014 American LegalNet, Inc. www.FormsWorkFlow.com 1A005e MC: <F023> Attorney General Case #: <F003> REVOCATION OF 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 By submitting this completed, signed, and dated form, I am instructing the Office of the Attorney General (OAG) to do the following: (You must place your initials next to each item that applies.) Revoke my authorization to release information or records on my case (OAG number given above) Do not release any information or records to the following person: Name :_________________________________________________________ Address : _______________________________________________________ Phone Number: __________________ City, State: ______________________ Zipcode: ___________ Initials:________ I understand that information or records will no longer be sent to the above named person unless I submit another Authorization for Release of Information or Payments form. Revoke my authorization to send payments to another person. Do not send any more payments to the following person: Name:_________________________________________________________ Address:_______________________________________________________ Phone Number:__________________ City, State: ______________________ Initials:_________ Zipcode:____________ I understand that payments will no longer be sent to the above named person unless I submit another Authorization for Release of Information or Payments form. 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 November 2014 1A005e