Download County of Santa Clara Social Services Agency Condado de Santa

County of Santa Clara
Condado de Santa Clara
Social Services Agency
Agencia de Servicios Sociales
RETURN TO:
,
REGRESE A: (Nombre de trabajador/a) (Numero de trabajador/a)
Your agency address is:
La direccion de su oficina es:
Dia chi van phon phu trach ho so ban:
Select one,
Yo/Nosotros
Living at
Viviendo en
Hereby authorize you to release to the Department of Family and Children’s Services specific information requested
by the Department of Family and Children’s Services concerning:
Por medio de la presente, autorizo que Ud. ceda a la Agencia de Servicios Sociales del Condado de Santa Clara cierta informacion especifica
solicitada por ellos con respecto a:
Hereby authorizes the Department of Family and Children’s Services to release medical, psychiatric, economic,
criminal, or social information:
Por medio de la presente, autorizo que la Agencia de Servicios Sociales del Condado de Santa Clara ceda informacion medica, psiquiatrica,
economica, criminal, o social con respecto a:
Complete for Requests to County Health Department
This disclosure of records is required for the following purpose:
Verification of eligibility for public assistance.
Other:
Unless expressly limited or earlier revoked, this consent will end one year after the date signed, except when there is a
pending appeal or fair hearing when the time period shall be extended to the final disposition of the issue.
THIS FORM WAS
READ BY ME
READ TO ME IN ITS ENTIRETY, PRIOR TO SIGNING.
YO LEI O SE ME LEYO ESTA FORMA EN SU TOTALIDAD, ANTES DE FIRMARLA.
(Signature/firma)
Birthplace:
(Social Security No./Numero de Seguro Social)
(Date/Fecha)
ADDITIONAL INFORMATION (To be completed if needed)
Birthdate:
Maiden Name of Mother:
Signature or Name of Spouse:
Date:
Social Security Number:
Birthplace of Spouse:
Birthdate of Spouse:
Maiden Name of Spouse’s Mother:
Fastener 2 - Top
(Replaces ABCDM 228 in Santa Clara County)
SCZ 1029 (E/Sp) - 2/97