MC: <F023> Attorney General Case #: <F003>
AUTHORIZATION FOR RELEASE OF INFORMATION OR PAYMENTS
Print your current name: _____________________________________________________________________________________
Other names you have used: __________________________________________________________________________________
Name of the other party in the case: ____________________________________________________________________________
Names of all children on this case: _____________________________________________________________________________
OAG Case Number (10 digit number included in OAG correspondence about this case): __________________________________
Phone number where you can be contacted:( ____ )_________________
You do not have to redirec
t your payments in order to release information or records. The two choices provided below are
independent of each other.
By submitting this completed, signed, and dated form, I authorize and request the Office of the Attorney General (OAG) to do the
following: (You must place your initials next to each item that applies.)
Release information or records on my case
(OAG number given above)
Initials:________
This person is (check one)
y
Name :_________________________________________________________
Phone Number: __________________
A ddress : _______________________________________________________ City, State: ______________________
Zipcode: ___________
OR
Send any payments on my case (OAG number given above) to the
person I am naming below. I understand that this may delay my
receiving my payment. I also understand that this revokes any direct
deposit authorization that I have already given to the Office of the
Attorney General.
This person is (check one)
Initials:_________
Name: _________________________________________________________
Phone Number:__________________
Address:_______________________________________________________ City, State: ______________________ Zipcode:____________
I understand that this authorization automatically expires if the case is closed. I may choose to revoke this authorization at any
time by submitting a completed, signed, and dated Revocation of Authorization for Release of Information or Payments.
I understand that the Oce of the Attorney General of Texas is not responsible for disputes between the listed party and me as a
result of this arrangement. (Please note the date of your signature is required.)
______________________________________ _____________________________
Signature Date (required)
______________________________________
Address
______________________________________
City, State, ZIP
November 2014 1A004e
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signature
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