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):

 

 

 

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

(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)

 

______________________________________              ____________________________________

Signature of Affiant                                                    Date

 

 

             Requestor’s RIN:                                                                                     Notary Public

 

Please mail the completed form to the Illinois State Disbursement Unit at the above address.