Releases To Obtain Information For Verification Form. This is a Oregon form and can be use in Marion Local County.
Tags: Releases To Obtain Information For Verification, Oregon Local County, Marion
S T AT E O F OR E G ON RELEASES TO OBTAIN INFORMATION FOR VERIFICATION Marion County Case No(s). SECTION 1 I understan d that th e court ve rifies m y em plo ym ent and financial situation to determine my eligibility for a court-appointed atto rney. I understand that some of the information necessary for this verification is contained in records that may be protected by federal and state law. Because of this, I have signed releases below which allow public and private organizations and individuals to provide the co urt or its d esignee with reque sted inform ation. I understand that organizations and individuals that may be contacted include, but are not limited to, those listed below: g Social Security Administration g State Department of Revenue g Department of Motor Vehicles g Employment Department(s) g W orke rs’ Co m pensatio n D isability P rovider g Adult and Family Services Division g Private Disability Insurance Provider g Private Life Insurance Provider g Release Assistance Office g Credit Card Companies g Banks, Savings and Loans, Credit Unions (requesting savings, stocks, bonds, checking, loan, and credit information including copies of applications) g Mortgage Holders g Utility Com panies g Landlords g Past Em ployers g Credit Bureaus g Schools and Colleges g OTHER SECTION 2 Specifically, by signing this release, I authorize the court or its designee to directly contact my current employer(s) by telephone or in writing and to release and utilize my address and Social Security number, if provided, as needed by the court or its designee. I understand that this release remains in effect six months or until my case(s) is concluded or until I send a written request to the court revoking the release. DATE SECTION 3 SIGNATURE OF APPLICANT RELEASE OF INFORMATION AUTHORIZATION Verification Office Marion County Circuit Court P.O. Box 12869 Salem, OR 97309-0869 Nam e Social Se curity No. Date of Birth I understand that my records may have information that is protected by federal and state law. By signing below, I am allowing the release of my records directly to the court or its designee named above. I understand the reason for the request and disclosure of my records. I understand that this release remains in effect six months or until my case(s) is concluded or until I send a written request to the court revoking the release. A photocopy or facsimile (FAX) of my signature is as valid as the original. DATE SIGNATURE OF APPLICANT SECTION 4 EMPLOYMENT DEPARTMENT RELEASE OF INFORMATION AUTHORIZATION Nam e Verification Office Marion County Circuit Court P.O. Box 12869 Salem, OR 97309-0869 Social Se curity No. Date of Birth I authorize the Employment Department, State of Oregon, to release to the court or its designee named above, information from my records on file with the Employment Department. I understand that this release remains in effect six months or until my case(s) is concluded or until I send a written request to the court revoking the release. IDEF-100:9/01 DATE SIGNATURE OF APPLICANT American LegalNet, Inc. www.USCourtForms.com