Page 495

GOVERNMENT OF THE DISTRICT OF COLUMBIA DEPARTMENT OF HUMAN SERVICES

Income Maintenance Administration

Authorization for Release of Information

I hereby authorize the Department of Human Services, Income Maintenance Administration, to release the information contained in my case file to . I understand that this request will expire thirty (30) days from the signature date below.

Customer Signature

Date

DHS Form: 495-ARI (05/03)

645 H Street, NE, Washington, DC 20002 – (202) 698-3900