General Assistance Authorization of Disclosure General Consent Form

Municipality of ____________

General Assistance Authorization of Disclosure
General Consent Form

I, ____________________________________________________ authorize the Municipality of ______________________________________________________________to disclose to _________________________________________________________, at the following address _____________________________________, the following information from my records:

______________________________________________________________________________

The purpose or need for such disclosure is: _____________________________________________

______________________________________________________________________________

I understand that this consent to disclose may be withdrawn by me at any time except where action has already been taken based upon my consent. This consent (unless clearly withdrawn in writing earlier) expires on ______________________________________________________________
(specify date, event or condition upon which consent shall expire)

I am signing this General Consent Form voluntarily.

Client Signature: _______________________________________ Date:_____________

Witness Name: ________________________________________ Date:_____________

Witness Signature: ____________________________________

*Optional*

ACKNOWLEDGMENT

State of Maine

____________________________, S.S.
(County)

Place:_________________________

Date: __________________________

Personally appeared before me the above named ______________________________________ and acknowledged the above disclosure to be his/her free act and deed.

Before me, _____________________________________________________________________
(Justice of Peace, Notary Public, Attorney at Law)