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WASHINGTON COUNTY DEPARTMENT OF JOB AND FAMILY SERVICES P. O. BOX 2005 1115 GILMAN AVENUE MARIETTA, OHIO 45750 Phone: (740) 3735513 Fax: (740) 3739790 AUTHORIZATION FOR RELEASE OF INFORMATION I, the

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Begin by completing the heading section of the form, which includes your name, social security number, and contact information.

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Next, identify the specific information you are releasing by providing details such as the document title, date, and any corresponding case or reference numbers.

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In the "Purpose of Release" section, clearly state the reason for disclosing the information and any specific individuals or organizations who are authorized to receive it.

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