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AUTHORIZATION TO RELEASE INFORMATION <br />I, give my consent for Anoka County Rule 25 staff to speak <br />(APPLICANT'S NAME) <br />with <br />(NAME/PROVIā‘ER) (RELATIONSHIP TO APPLICANT) <br />to obtain information in order to complete my Rule 25 eligibility determination for funding. <br />I understand that the information received will only be used for the purpose of assisting in the determination of <br />Rule 25 funding in reference to my Rule 25 application. <br />This Includes: -Appointment dates <br />- Verification requests <br />- Application status <br />I understand that the Minnesota Government Data Practices Act and other laws require that this data remain <br />private. This data cannot be released without my consent except as provided by law. I understand why I am <br />begin asked for this information. With my consent, this information could be shared with only the person <br />stated above. I understand that if I refuse to release information the information will not be released unless <br />the law otherwise allows its release. If I consent, this information will be used in the determination of eligibility <br />for Rule 25 funding. My consent will expire one year form the date of my signature. A photo copy of this <br />consent may be treated in the manner as the original. I may cancel this consent by written request to Anoka <br />County Rule 25 staff. <br />(PRINT FULL NAME) (APPLICANT'S SIGNATURE) <br />(TODAY'S DATE) <br />