ILLINOIS

STATE DISBURSEMENT UNIT

P.O. Box 5921

Carol Stream, IL 60197-5921

Customer Service: (877) 225-7077

 

CONSENT TO RELEASE CONFIDENTIAL INFORMATION

 

I, __________________________________________, whose birth date is _________________________,

     Requestor’s name as found in department records                                                  Month / Day / Year

 

Authorize the Illinois State Disbursement Unit to disclose to:

 

______________________________________________________________________________________

       Your (participant) name or person or organization to which disclosure is to be mailed/provided

 

The following information pertaining the below listed docket number(s):

 

Docket Number

 

Issuing County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

(Nature of the information to be disclosed – purpose for disclosure)

 

This consent expires on: __________________________________________________________________

(This consent automatically expires 120 days from the date notarized, unless the above date extends it)

 

______________________________________                       ____________________________________

                        Your Signature                                                                       Your Social Security Number

 

Mail To Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

State:

 

Zip:

 

Your (Participant) day time phone number:

 

 

 

 

 

Imaging Category: Miscellaneous

For Agency Staff Use Only:

_________________________________

Custodial Parent’s RIN:

_________________________________

Requestor’s RIN:

 

Subscribed and sworn to before me this

 

________ day of _________, 20_______,

 

__________________________________

Notary Public

 

Please fax the completed form to (630) 221-2312 or mail to the Illinois State Disbursement Unit at the above address.