Authorization For Release Of Information {IN-014}

In the Court of Common Pleas of WESTMORELAND County, Pennsylvania DOMESTIC RELATIONS SECTION 2 N MAIN ST., SUITE 302, GREENSBURG, PA 15601 Phone: (724) 830-3200 Fax: (724) 830-3256 Plaintiff Name: Defendant Name: Docket Number: PACSES Case Number: Other State ID Number: Please note: All correspondence must include the PACSES Case Number Authorization for Release of Information Re: SSN: I do hereby authorized and request the disclosure to the Domestic Relations Section of any information that may be desired concerning my age, residence, citizenship, employment, applications for employment, income, resources, medical or psychological history and school records. It is understood that the information obtained will be used for purposes directly related to my Domestic Relations case. A copy of this authorization shall be considered valid. _______________________________ Witness _________________________________ Signature __________ Date _______________________________ Title Service Type Form IN-014 Worker ID American LegalNet, Inc. www.FormsWorkFlow.com