SFN 1059, Authorization to Disclose Information 400-19-165-110

(Revised 6/1/10 ML #3218)

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The purpose of the SFN 1059 is to request information on a specific individual from a single agency.  Information requested must be required to determine eligibility and benefit level.

 

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms. (166kb pdf)

Note: E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader.  If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.