Hr3189 2025

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154 votes

The document is a consent form for the disclosure of personal information collected under the Employment and Assistance Act and related legislation. It outlines the rights of individuals regarding their personal information, specifies the types of information that can be disclosed, and requires client details along with consent for sharing this information with designated agencies or individuals.

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Click ‘Get Form’ to open hr3189 in the editor.
Begin by entering your Client Name and Birth Date in the designated fields. Ensure that the information is accurate as it is crucial for processing.
If applicable, fill in your SR Number and Case Number. These identifiers help streamline your application process.
In the consent section, specify any limitations on the disclosure of your personal information. Use the provided space to detail specific information if necessary.
Indicate which types of assistance you are consenting to disclose information for by checking the relevant boxes: Income Assistance, Hardship Assistance, Disability Assistance, or Supplements.
Provide details about the agency and individual who will receive this information. Fill in their names, addresses, and contact numbers accurately.
Finally, sign and date the form at the bottom. If signing on behalf of someone else, remember to attach proof of legal authority.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (154 Votes)

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