Department Of Health And Human Services Record Release Authorization
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Department Of Health And Human Services Record Release Authorization Form. This is a New Hampshire form and can be use in Probate Court Statewide.
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Tags: Department Of Health And Human Services Record Release Authorization, NHJB-2171-FP, New Hampshire Statewide, Probate Court
THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us
Court Name:
Case Name:
Case Number:
(if known)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
RECORD RELEASE AUTHORIZATION
To:
(RSA 170-B:18, VI and 463:5, VI and 464-A:4, V)
Department of Health and Human Services and all its divisions
I hereby authorize the release of any child or adult abuse and/or neglect record that you may find
concerning me to the (name of court)
, at
(address of court)
1.
Name
Mailing address
2.
Also known by following names (example: maiden name)
3.
Date of birth
4.
List other states where you have resided as an adult and when
I understand that the information disclosed and provided by you under this request and release
authorization is intended for use by the above named court, in conjunction with the above referenced
matter and subject to any confidentiality requirements applicable to such legal proceeding.
Date
Signature
State of
, County of
This instrument was acknowledged before me on
by
Date
My Commission Expires
Affix Seal, if any
Person Signing Above
Signature of Notarial Officer / Title
The court requires that the search be conducted and the information be provided as specified above.
PER ORDER OF THE COURT,
Date
NHJB-2171-FP (08/31/2009)
(formerly AOC-232-003)
Register of Probate / Regional Court Clerk
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