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When asked to release information necessary to process an application, the date and the name of the person or organization from which information is being requested must be listed on the release form prior to requesting the client’s signature. • This policy applies to the Authorization for Release of Information Form, or any of the other forms used to document the client’s authorization for the release of confidential information. • All forms of this type must show the date of the client’s signature and may not be honored if more than 90 days old. The client may also revoke this authorization at any time prior to the expiration of the release. 2025.05.15 CLIENT ATTESTATION AND WRITTEN STATEMENTS

When all reasonable attempts have been made but neither the worker nor the client can secure the necessary documentation, the client's signed statement is to be acceptable information. The signed statement will serve as verification of the given eligibility element.

Client Attestation cannot be used for any of the following: • Citizenship or Immigration status • Social Security number • Legal documentation that includes but not limited to trusts, wills, court orders, or contracts.

If a written statement is submitted, the statement must include the client’s best estimate of the information that was requested (for example, date employment ended if the former employer refuses to write a statement for the client). The statement must be dated and signed by the client.

Note: All written and attested statements must include a signature, date, and give specific monetary/frequency terms of actual/anticipated projections of information when applicable.

EXAMPLE:

“My mother gave me a total of $25 in the month of May, and it was only for one month” or “My mother gives me $200 per month each month to assist with expenses”, or “My last day of employment at ABC company was January 5th.”

The worker must document the reason for the signed statement (i.e., case notes could read “Client states previous employer would not give them a statement showing their last day of employment, accepted handwritten statement from client stating last date employed.”)

Note: If the client verbally provides information over the phone rather than in writing, this must be properly documented in case notes.

EXAMPLE: