111 LN Release To or From Another Agency
Please fill out this form which will enable SOFA to share information with another agency on your behalf.
Sign in to Google to save your progress. Learn more
Husband and Wife First and Last Names *
Name, Address and Contact Information of Other Agency *
I authorize the following information to be released and exchanged: *
This authorization will remain in effect for 90 days or until the following condition/event is met
We understand that we have the right to revoke this authorization at any time by submitting a written request to appropriate agency personnel.  This revocation will be effective, except to the extent that Spirit of Faith Adoptions has already taken action in reliance on my authorization.  
NOTE: Federal law and regulations do not protect any information about a crime committed by a client, either at the program or against any person who works for the program, or about any threat to commit such a crime.  Federal law regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities. (See 42 USC 290 DD-3 and 42 USC 290 EE-3 for Federal Laws and 42 CFR Part 2 for Federal Regulations.)  
This information has been disclosed to you from records protected by Federal confidentiality rules.  The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR, Part 2.  
If this authorization is signed by a representative on behalf of an individual, his/her authority or relationship to act on behalf of the individual must be set forth here:
We have read this form and/or it was read to me and explained in language we can understand.  We are aware of the consequences that might occur as a result of signing this consent form or of my refusal to do so.  All blank spaces have been filled in except for signature and dates.  
Husband's Printed Name for Signature *
Wife’s Printed Name for Signature *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Spirit of Faith Adoptions. Report Abuse