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This is a Missouri form that can be used for Family Court within Local Circuit Courts, 16th Circuit (Jackson County).
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AUTHORIZATION TO DISCLOSE FINANCIAL RECORDS To: ________________________________ ________________________________ ________________________________ Re: ________________________________ SSN. ___________________________ You are hereby authorized and directed to furnish and release to ________________________________ ____________________________________________________ and to any employee, agent or representative thereof any and all or any portion of the records, documents and other writings and information in your possession or under your control concerning all of my accounts with and deposits in your institution, whether open or closed, and whether held solely in my name or jointly with another and further concerning all my loans and lines of credit with your institution on which I am liable individu or jointally ly with another or as a guarantor. You are further authorized to allow said persons tead, review, copyo r and have copied any and all records, notations, memoranda, and all other recorded information regardless of whether it is written, recorded, or on computerized disc. You are also authorized to communicate with said persons orally or in writing and to provide reports concerning the matters addressed herein for the purpose of explaining or disclosing any other information requested relative to such accounts and deposits. All expense pertaining to the foregoing shall be paid b the pary ty requesting the information pursuant to this authorization and nothing herein shall be construed to make me liable for those costs. ________________________________ STATE OF MISSOURI ) ) ss. COUNTY OF __________ ) On this _____day of____________, 20____, before me, a Notary Public, personally appeared the above named person who acknowledged signing tabove and fhe oregoing instrument as a free act and deed. ______________________________ Notary Public My Commission Expires: Form 1402I Adopted 11/17/95