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Permission to Access DTA Client Record (Client Consent Form) - English


The attached form (in English and Spanish), in PDF and Word, is a sample client consent form that helping agencies can use in order to speak with DTA about a specific case record or get copies of documents in the caser record. A client can also hand write the same information on a blank piece of paper that gives written permission or consent for a helping agency or individual to speak with DTA. Exceptions apply for victims of domestic violence. 

Individuals who are acting on behalf of and/or financially managing the SNAP or cash benefits of an elder or disabled household will be need to sign a different DTA form called a "Request to Choose Someone to Be My Authorized Representative" (Image 10 form). Agencies serving as authorized representatives need to complete the Image 10 form.  DO NOT confuse the purpose of these forms!  

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