Free Kansas Social and Rehabilitation Services Application for Information - Kansas

KANSAS SOCIAL AND REHABILITATION SERVICES APPLICATION FOR INFORMATION In Accordance With K.S.A. 39-709b and Kansas Administrative Regulation 30-2-11 I, ___________________________________, Social Security Number ____/___/_____, hereby request the Kansas Social and Rehabilitation Services to disclose and provide to the law firm of ____________________________________________________________________________, information I previously submitted to SRS or was supplied to me by SRS, or SRS records concerning me or my children, as follows: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ My information request is for the following purpose(s): ______________________________________________________________________________ ______________________________________________________________________________ I further authorize and consent to the disclosure and copying of these records for the above mentioned purposes. IN CONSIDERATION OF SUCH DISCLOSURE ON THE PART OF THE ABOVE NAMED PERSONS AND/OR INSTITUTIONS, I HEREBY RELEASE THEM FROM ANY AND ALL LIABILITY ARISING THEREFROM AND AGREE TO HOLD THEM HARMLESS FROM ANY LIABILITY RESULTING THEREFROM. Date ____________________ Signed __________________________________

STATE OF _________________________ ) ) ss: COUNTY OF ________________________ ) BE IT REMEMBERED, that on this _____ day of ___________________, 20_____, before me personally appeared _____________________________, know to me to be the person named in and who executed the foregoing instrument of writing and acknowledges the execution of the same.

____________________________________ Notary Public My Appointment Expires: __________________________
Revised: 5-19-99