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Kansas Social And Rehabilitation Service Application For Information - Kansas
| Kansas Social And Rehabilitation Service Application For Information Form. This is a Kansas form and can be used in Civil 3rd Judicial District (Shawnee County) Local District Court . |
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KANSAS SOCIAL AND REHABILITATION SERVICES APPLICATION FOR INFORMATION In Accordance With K.S.A. 39-709b and Kansas Administrative Regulation 3 0-2-11 I, ___________________________________, Social Security Number ____/___/ _____,hereby request the Kansas Social and Rehabilitation Services to disclose and provide to the lawfirm of ________________________________________________________________________ ____,information I previously submitted to SRS or was supplied to me by SRS, or SRS recordsconcerning me or my children, as follows: ________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______ My information request is for the following purpose(s):________________________________________________________________________ ______________________________________________________________________________ ______ I further authorize and consent to the disclosure and copying of these r ecords for theabove-mentioned purposes. IN CONSIDERATION OF SUCH DISCLOSURE ON THE PART OF THE ABOVE NAMEDPERSONS AND/OR INSTITUTIONS, I HEREBY RELEASE THEM FROM ANY AND ALLLIABILITY ARISING THEREFROM AND AGREE TO HOLD THEM HARMLESS FROMANY LIABILITY RESULTING THEREFROM. Date ____________________ Signed __________________________________ BE IT REMEMBERED, that on this _____ day of ___________________, 20_____,before me personally appeared _____________________________, know to me to be the personnamed in and who executed the foregoing instrument of writing and acknow ledges the executionof the same. ______________________________ Notary PublicMy appointment expires: _________________
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