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Dove Financial Assistance <br /> CONSENT FOR RELEASE/EXCHANGE OF CONFIDENTIAL INFORMATION <br /> To be signed by households that intends to receive financial assistance. This form allows <br /> the Dove INC to discuss the case via an exchange of information. <br /> I, , authorize Dove Financial Assistance <br /> to release and exchange information with: <br /> ® DHS ❑ Northeast Community Fund <br /> ® Empowerment Opportunity Center ❑ HUD <br /> ❑ The Salvation Army ❑ Other: <br /> ❑ Macon County Continuum of Care <br /> Via the Oasis Software <br /> I have also been informed that I may, in writing to Dove Inc; revoke this consent for <br /> release/exchange of information at any time and this may affect my continued eligibility. <br /> Unless otherwise indicated, this consent for the release/exchange of the information <br /> indicated above will be valid for a period of 12 months after I apply. <br /> Head of Household Signature Date <br /> Staff Signature Date <br />