AFFIDAVIT OF AUTHORIZATION AND RELEASE OF INFORMATION I/We, an individual, heir, personal representative of deceased, or owner/authorized company officer, hereby authorize all creditors and/or their agents to discuss our account and provide any and all documentation with representative(s) of Lost Money Finders. whom we have given power-of-attorney to handle settlement arrangements on our payable accounts. I acknowledge that my name & address are true and this representation is made under oath in order to receive payment of unclaimed funds. The information being requested is for use in connection with a bona fide “permissible purpose” as defined in Section 504 of Public Law 91-50. A copy of this authorization may be accepted as original. Further, we release all creditors or agents from any wrong doing in discussing any aspect of the nature of the account in question with representatives of Lost Money Finders. _____________________________________ ____________________________________________ Signature Witness #1 signature / printed name ____________________________________ Printed Name ___________________________________________ ______________________________________ Witness #2 signature / printed name Address STATE OF _______________________ COUNTY OF _____________________ BEFORE ME, the undersigned authority, personally appeared ________________________who is personally known by me or who has produced ______________________as identification and who by me was first duly sworn and cautioned, states that he/she executed the foregoing and the contents thereof are true and correct. IN WITNESS my hand and official seal, this ____day of ______________, 20______. My Commission Expires:__________________ Notary Public (Seal) Please copy your driver’s license onto this area. Please copy a second form of ID onto this area. Each individual involved must fill out and submit a separate “Authorization and Release of Information”.
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