Voluntary Authorization For Release Of Information

VOLUNTARY AUTHORIZATION FOR RELEASE OF INFORMATION Please complete the information below in its entirety. Only those forms which are completed in full will be deemed proper for release of child support records. Where applicable, use your complete name and the complete name and address of the authorized person(s). I , hereby authorize the following person(s) access to view information contained in my records with Licking County Child Support Enforcement Agency found under case number(s) & as of this date: and ending as of the following date: .I understand that without this authorization, the CSEA may be prohibited from releasing information to any other persons. Name of applicant Address of applicant Date signed NAME OF AUTHORIZED PERSON(S) TITLE/RELATIONSHIP ADDRESS: American LegalNet, Inc. www.USCourtForms.com