Release of Information Form

 

Here’s what the Release of Information form says:

I (We), _____________________________________________________________________________,

_____________________________________________________________________________ ,

Give my (our) permission to Friends of Veterans, Inc. (FOV) to advocate on my (our) behalf on those issues that I (we) have requested assistance in obtaining (housing, food, other basic needs, referral to other agencies, etc). I (we) understand that in advocating on my (our) behalf, it may be necessary to obtain or share sensitive or confidential information regarding me (us) or my (our) family and to verify information included in my application for assistance, but that it will only be done to assist with my (our) request for assistance. I (we) further understand that all information is used only to meet advocacy needs and that it otherwise remains in strict confidence. I (we) understand that FOV works with other agencies to obtain monies or other needs in helping me (us). I (we) understand that I (we) may be referred to other agencies for help before FOV contributes any funds to me (us). I (we) agree to follow through with referrals to other agencies for help. I (we) understand that there is no obligation to repay any assistance received from FOV, or to make any future donation to FOV. I (we) understand that FOV is unable act on this request for assistance prior to receiving this signed Release of Information form.

I (we) further agree that FOV may transmit my (our) application request and documents to other agencies whom FOV believes may be in a position to support my (our) financial needs.

Signature______________________________ _Printed Name________________________________Date_______________ Signature____________________________Printed Name____________________________Date______________

Phone Number______________________ E-mail address (if applicable)____________________________________

After completing and signing this form, please return to FOV by mail, fax or email to: Friends of Veterans, Inc.
28 Farmvu Drive, Suite 3 White River Junction, VT 05001
802-296-8368 (telephone); 802-296-3663 (fax); assistance@fovvtnh.org (email)

Download the Release of Information form HERE.

 

Fill out and then fax, mail, or hand-deliver to FOV office, or you may scan or take a photo of it and email a legible copy to us.

Please note that FOV cannot process your request for assistance until we receive this form.