A. _______________________, hereby authorize the Long Term Recovery
Client Name
Committee to release to the agency or person designated below any
information maintained by the Long Term Recovery Committee that is relevant for the
purpose of providing assistance for my disaster needs caused by
____________________________.
Name of Disaster
B. ________________________, hereby authorize the agency or person
Client Name
designated below to release to the Long Term Recovery Committee any
information maintained by the agency or person relevant and necessary for the purpose of
providing assistance for my needs caused by
_____________________________________.
Name of Disaster
C. I further understand that the release of information does not guarantee that assistance will be provided, but that without the information my case cannot be presented to the Long Term Recovery Committee for consideration.
| Name of Agency or Person Designated to receive the information: ______________________________ |
| ______________________________ Signature of Client (Head of Household) |
__________________________ Signature of Client (Spouse) |
| ___________ *Identification |
________ Date |
___________ *Identification |
________ Date |
| ______________________________ Signature of Client (Head of Household) ____________________________ |
__________________________ Signature of Client(Spouse) ____________________________ |
| Pre-disaster address of client: ____________________________ ____________________________ ____________________________ |
* Identification should verify client’s
pre-disaster address. (Driver’s license, utility bill, etc.)
** Control number is not a guarantee of assistance from FEMA. It is for
tracking purposes only.