INFORMED CONSENT RELEASE FORM
1. As permitted by § 8-625(d)(1) of the Labor and Employment Article, Annotated Code of Maryland and by
federal regulations under 20 C.F.R. part 603, this signed form releases certain confidentiality rights of the
undersigned.
2. This consent form will remain in effect until the District Court Commissioner’s obligation to maintain these
records for its files has terminated, revocation by the undersigned, or five (5) years.
3. Please provide the undersigned individual’s name(s) (include all other names you have used for the period of
time the records are requested):
4. Please provide the undersigned individual’s Social Security Number:
5. The undersigned acknowledges that this signed form permits access to confidential information maintained by
the Maryland Department of Labor, Division of Unemployment Insurance. This information includes wage
history, employment history, and the number and amount of Unemployment Insurance benefits received by
the undersigned.
6. The undersigned individual consents to the Office of the District Court Commissioner or its designee to
review confidential information, including benefits information and wages earned by the individual and
reported by his or her employer for purposes of evaluating the individual’s qualification for a Court-appointed
attorney. The determining of whether the undersigned qualifies for a Court-appointed attorney may assist the
undersigned in a legal matter.
7. The confidential information will be disclosed only to the Office of the District Court Commissioner or its
designee. The information disclosed pursuant to this release will be used only for the purposes stated in this
release, which is to determine whether the undersigned qualifies for representation by the Office of the Public
Defender to assist the undersigned in a legal matter.
DC-099A (Rev. 07/2019)
Signature of Consenting Individual
