Free Department of Health & Human Service Record Release Authorization - New Hampshire


File Size: 37.4 kB
Pages: 1
Date: December 30, 2008
File Format: PDF
State: New Hampshire
Category: Court Forms - State
Author: NHJB
Word Count: 220 Words, 1,364 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.courts.state.nh.us/forms/nhjb-2171-fp.pdf

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Instructions

Clear Form

THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us

Court Name: Case Name: Case Number:
(if known)

DEPARTMENT OF HEALTH AND HUMAN SERVICES RECORD RELEASE AUTHORIZATION
(RSA 170-B:18, VI and 463:5, VI and 464-A:4, V)

To:

Department of Health and Human Services and all its divisions I hereby authorize the release of any child or adult abuse and/or neglect record that you may find , at

concerning me to the (name of court) (address of court) 1. Name Mailing address 2. Also known by following names (example: maiden name)

3. 4.

Date of birth List other states where you have resided as an adult and when

I understand that the information disclosed and provided by you under this request and release authorization is intended for use by the above named court, in conjunction with the above referenced matter and subject to any confidentiality requirements applicable to such legal proceeding.

Date

Signature

State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any

, County of by
Signature of Notarial Officer / Title

The court requires that the search be conducted and the information be provided as specified above. PER ORDER OF THE COURT,
Date
NHJB-2171-FP (02/01/2008) (formerly AOC-232-003)

Register of Probate / Regional Court Clerk
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