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ESA SNAP Policy Manual 12 − Authorization of release—signed by the customer—from an attorney, legal advocate or other representative − Authorization for Release of Information (DHS Form 495-ARI)  If the request from the authorized representative is in writing, ESA may need to contact the customer to confirm the identity of the person requesting the customer’s information. The following information must be recorded in the case record: − The date of the disclosure − The name of the entity or person who received the information and, if known, the address of such entity or person − A brief description of the information disclosed − A brief statement of the purpose of the disclosure that reasonably documents the basis for the disclosure or, in place of such statement, a copy of a written request for a disclosure, if any  ESA must refer requests for deceased customers to the ESA Policy Unit for assistance.  ESA will forward any request by a customer for an accounting of all disclosures to the ESA Policy Unit, which will refer the matter to the ESA Privacy Officer as appropriate. 1.6.5 Requests for Information From All Other Parties ESA will refer requests to review a customer’s case record from an individual other than the customer or their authorized representative to the administrator. ESA will never disclose information to such persons in the absence of a signed, verified request from the customer. 1.6.6 Nonroutine Disclosures of Customer Information Only the administrator, or the administrator’s designee, may authorize the disclosure of customer information to a requester who is not an authorized representative of a customer. This policy includes all requests from law enforcement officials, unauthorized neighbors, subpoenas or any other source. The Office of the Administrator must maintain a log of all requests and copies of the correspondence between the administrator and the requester. The log must include the following information:  The date of the disclosure  The name of the entity or person who received the information and, if known, the address of such entity or person  A brief description of the information disclosed  A brief statement of the purpose of the disclosure that explains the basis for the disclosure or a copy of a written request for a disclosure The administrator must deny all requests unless the requester can provide proof that they are an authorized representative of the customer. Return