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CoH Financial Assistance Release

Creditor - Authorization for Release of Information

(Complete this section ONLY if applying for Financial Assistance)

Name of Creditor:

Creditor’s Phone #:

Date:

I authorize the Creditor listed above to release any information needed in order for Cradle of Hope to confirm and/or verify my need for financial assistance. I understand that this information will be used to determine if any assistance will be granted to me. This authorization will expire one year from the date indicated.

I certify that the information provided in this application is true and that any funds I receive will be used for the purpose stated in this application. I authorize Cradle of Hope and Agency representatives to verify and communicate any information contained in this application or about my situation to assist me. Cradle of Hope will maintain your confidentiality and will not release your information to other agencies without your consent.

Please type Client's First & Last Name AND Client's Email Address before the client signs this document:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

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April 10, 2020 4:22 pm CST

CoH Financial Assistance Release Uploaded by Darlene Kopesky - dkopesky@cradleofhope.org IP 73.62.185.83

April 10, 2020 4:40 pm CST

Darlene Kopesky - darlene.kopesky@gmail.com added by Darlene Kopesky - dkopesky@cradleofhope.org as a CC'd Recipient Ip: 24.118.77.131

April 10, 2020 4:45 pm CST

Darlene Kopesky - darlene.kopesky@gmail.com added by Darlene Kopesky - dkopesky@cradleofhope.org as a CC'd Recipient Ip: 24.118.77.131

April 10, 2020 5:01 pm CST