Professional legal forms

Prds application to rent or le... Kate's Properties Equal Housing Opportunity RENTAL LEASE APPLICATION Checklist 1. 2. 3. 4. 5. 6. Initial at the end of all pages. Complete the Rental Lease Guarantor application if required. Verify

Commercial lease application f... NATIVE LAND TRUST BOARD APPLICATION TO LEASE PURPOSES OTHER THAN AGRICULTURAL Note: 1. Applicant to fully complete this Form. 2. The following Information must be submitted with this form. (a) (b)

Application for bond release o... STATE OF OKLAHOMA DEPARTMENT OF MINES 2915 N. CLASSEN, SUITE 213 OKLAHOMA CITY, OKLA. 73106 APPLICATION FOR BOND RELEASE (Return all three (3) sets) Date Company Name Company Mailing Address City

Tennessee form release Please Allow 20 Business Days for Response As Required by TCA 71-5-116 c 2 STATE OF TENNESSEE BUREAU OF TENNCARE TPL Division 310 Great Circle Road 4th Floor Si usted necesita esta forma en Espa ol por favor llame al 1-866-389-8444 NASHVILLE TENNESSEE 37243 Toll Free 866-389-8444 FAX 615 413-1941 TENNCARE ELIGIBILITY VERIFICATION/ REQUEST FOR RELEASE OF ESTATE RECOVERY COST CLAIM A COPY OF THE DEATH CERTIFICATE MUST ACCOMPANY THIS REQUEST Probate Case No. Date Probate Opened County of Probate Decedent s Information Decedent s Last Name Decedent s First Name Decedent s Middle Name or Maiden Name Married Divorced Single Never Married Decedent s Social Security No. Decedent s Marital Status Decedent s Date of Birth YOU MUST PROVIDE INFORMATION REGARDING THE DECEDENT S SPOUSE IF APPLICABLE Is the Decedent s Spouse Pre-Deceased Yes No Spouse s Date of Death if Pre-Deceased Spouse First Name mm-dd-yyyyy Spouse Middle Name or Maiden Name Spouse Date of Birth Spouse Social Security No. The person completing this document is the Executor Representative Legal Counsel for the Estate. Name Address Phone Signature of Person Completing This Document ARE YOU REQUESTING AN EXEMPTION DUE TO SURVIVING SPOUSE* IF YOU ARE YOU MUST PROVIDE THE FOLLOWING INFORMATION AND/OR DOCUMENTATION IN ADDITION TO WHAT IS INDICATED ABOVE A copy of your marriage license. THIS DOCUMENT WILL NOT BE PROCESSED WITHOUT ALL INFORMATION REQUESTED SIGNATURE TC-0087 representation when advising the value of TennCare s claims and/or executing a release or deferral of TennCare s claim* TennCare shall be held harmless of any action brought by heirs or other interested parties due to the payment of TennCare s claim by the person presenting themselves as the estate representative. Notice CONFIDENTIAL INFORMATION REGARDING A TENNCARE RECIPIENT DECEASED TENNCARE RECIPIENT AND/OR NON-TENNCARE DECEASED PERSON WILL NOT BE RELEASED WITHOUT PRIOR AUTHORIZATION FROM THE EXECUTOR/EXECUTRIX ESTATE REPRESENTATIVE and/or LEGAL COUNSEL FOR THE ESTATE* INSTRUCTIONS PROVIDE ALL REQUESTED INFORMATION AND SIGN the TENNCARE ELIGIBILITY VERIFICATION/REQUEST FOR RELEASE FORM. You must provide information about the deceased person and the deceased person s spouse even though the spouse may have pre-deceased the decedent and the executor or estate representative must sign the request. PROVIDE A COPY OF THE DECEDENT S DEATH CERTIFICATE OR OTHER DOCUMENTATION AS INDICATED ON THE RELEASE* PROVIDE AN ADDRESS FOR RETURN OF THE RELEASE FORM. THE RELEASE FORM WILL NOT BE FAXED. THE FORM MAY BE RETURNED WITHOUT A COVER LETTER BUT YOU MUST PROVIDE A RETURN ADDRESS* IF YOU HAVE QUESTIONS REGARDING THE COMPLETION OF THE REQUEST FOR RELEASE FORM PLEASE CALL 866 389-8444. INFORMATION YOU SHOULD BE AWARE OF WHO IS SUBJECT TO RECOVERY ANY PERSON OVER 55 YEARS OF AGE FOR WHOM TENNCARE HAS PAID FOR NURSING FACILITY SERVICES OR CARE RECEIVED FROM HOME COMMUNITY BASED SERVICES* IF THE ESTATE IS NOT BEING PROBATED YOU DO NOT HAVE TO PROVIDE THE PROBATE COURT INFORMATION BUT YOU MUST OBTAIN A RELEASE OF TENNCARE S CLAIM PRIOR TO DISBURSEMENT OF FUNDS AND/OR ASSETS* HOW MUCH WILL THE PERSON S ESTATE HAVE TO PAY BACK TO TENNCARE THE ACTUAL VALUE OF ALL FUNDS EXPENDED BY TENNCARE FOR THE PERSON S COST OF SERVICES IN A NURSING FACILITY AND/OR HOME COMMUNITY BASED SERVICES* WHAT ARE THE EXEMPTIONS IF THERE IS A SURVIVING SPOUSE TENNCARE WILL NOT RECOVER FROM THE ESTATE UNTIL THE TIME OF THE SURVIVING SPOUSE S DEATH IF 1.

Lien release form mn Dps. mn.gov N otif ic ation of A s s ignm e nt Rele ase or Grant of Se cure d Inte rest Instructions on reverse side YEAR MAKE TYPE MODEL VEHICLE IDENTIFICATION NUMBER OWNER S NAME SECURED PARTY S NAME STREET ADDRESS TITLE NUMBER CITY STATE ZIP CODE A SIGNATURE OF OWNER S NECESSARY ONLY WITH GRANT SIGNATURE AND TITLE OF AUTHORIZED AGENT X ASSIGNMENT RELEASE GRANT The secured party named in Section A has assigned his interest to the secured party named in Section B. vehicle described above. Date of Release The owner s have granted to the secured party named in Section A a security interest in the vehicle described above. Date of Security Agreement --- NOTICE --This form must be notarized to release a lien. Subscribed and sworn to before me this day of ASSIGNEE S NAME NECESSARY ONLY WITH ASSIGNMENT NOTARY PUBLIC B PS2017-10 6/11 COUNTY - over - MY COMMISSION EXPIRES INSTRUCTIONS ASSIGNMENT OF LIEN 1. MINNESOTA DEPARTMENT OF PUBLIC SAFETY Print Form DRIVER AND VEHICLE SERVICES 445 Minnesota Street Saint Paul MN 55101-5187 Phone 651 297-2126 Web dvs. dps. mn*gov N otif ic ation of A s s ignm e nt Rele ase or Grant of Se cure d Inte rest Instructions on reverse side YEAR MAKE TYPE MODEL VEHICLE IDENTIFICATION NUMBER OWNER S NAME SECURED PARTY S NAME STREET ADDRESS TITLE NUMBER CITY STATE ZIP CODE A SIGNATURE OF OWNER S NECESSARY ONLY WITH GRANT SIGNATURE AND TITLE OF AUTHORIZED AGENT X ASSIGNMENT RELEASE GRANT The secured party named in Section A has assigned his interest to the secured party named in Section B. vehicle described above. Date of Release The owner s have granted to the secured party named in Section A a security interest in the vehicle described above. Date of Security Agreement --- NOTICE --This form must be notarized to release a lien* Subscribed and sworn to before me this day of ASSIGNEE S NAME NECESSARY ONLY WITH ASSIGNMENT NOTARY PUBLIC B PS2017-10 6/11 COUNTY - over - MY COMMISSION EXPIRES INSTRUCTIONS ASSIGNMENT OF LIEN 1. The Assignor must be listed as secured party on the application for title or on the current certificate of title. 3. The assignment must be submitted with the current certificate of title. 4. Fees 1 plus 10 filing fee. For an assignment noted concurrently with the secured interest no fee is required* The assignment accompanies the granting of a second interest. 3. The form must be notarized 4. This release must be submitted with the current certificate of title. 5. Fee 10 filing fee 1. The owner of the vehicle must complete section A of this form* 2. The grant must be submitted with the current certificate of title. All forms and fees may be submitted to your local motor vehicle office or you may make the check payable to Driver and Vehicle Services and mail the forms to Driver and Vehicle Services Suite 187 St* Paul Minnesota 55101-5187. MINNESOTA DEPARTMENT OF PUBLIC SAFETY Print Form DRIVER AND VEHICLE SERVICES 445 Minnesota Street Saint Paul MN 55101-5187 Phone 651 297-2126 Web dvs. dps. mn*gov N otif ic ation of A s s ignm e nt Rele ase or Grant of Se cure d Inte rest Instructions on reverse side YEAR MAKE TYPE MODEL VEHICLE IDENTIFICATION NUMBER OWNER S NAME SECURED PARTY S NAME STREET ADDRESS TITLE NUMBER CITY STATE ZIP CODE A SIGNATURE OF OWNER S NECESSARY ONLY WITH GRANT SIGNATURE AND TITLE OF AUTHORIZED AGENT X ASSIGNMENT RELEASE GRANT The secured party named in Section A has assigned his interest to the secured party named in Section B.

Leasedonation information in CG-ACGN ANNUAL CHARITY GAME NIGHT APPLICATION FOR FIRST TIME APPLICANTS State Form XXXXX INDIANA GAMING COMMISSION For Official Use Only License Fee Paid Date Received Reviewed By Date Entered INSTRUCTIONS:

Please mail this form to cbu p... City of Bloomington Utilities Individual Customer Contract Please mail this form to CBU, PO Box 2500, Bloomington, IN 47402-2500 Or Fax to (812) 331-5407 Please include a photocopy of your picture

Third party release form utah... THIRD PARTY RELEASE FORM Utah Department of Public Safety Bureau of Criminal Identification 3888 West 5400 South, Taylorsville, Utah 84118 WHEN FILLING OUT THIS FORM, TYPE OR PRINT IN BLACK INK. If

North coast life insurance com... North Coast Life Insurance Company 1116 West Riverside Avenue P.O. Box 1445 Spokane, WA 99210 509-838-4235 800-541-5858 www.nclife.com NORTH COAST LIFE INSURANCE COMPANY CHECKLESS REQUEST FORM PLEASE

Hipaa release formpdffillercom It can however be used more broadly than this and be used before litigation has been commenced or whenever counsel would find it useful. The goal was to produce a standard HIPAA-compliant official form to obviate the current disputes which often take place as to whether health information requests made in the course of litigation meet the requirements of the HIPAA Privacy Rule. OCA Official Form No. 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA This form has been approved by the New York State Department of Health Patient Name Date of Birth Social Security Number Patient Address I or my authorized representative request that health information regarding my care and treatment be released as set forth on this form In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 HIPAA I understand that 1. NYHIPAA 8/09 Instructions for the Use of the HIPAA compliant Authorization Form to Release Health Information Needed for Litigation This form is the product of a collaborative process between the New York State Office of Court Administration representatives of the medical provider community in New York and the bench and bar designed to produce a standard official form that complies with the privacy requirements of the federal Health Insurance Portability and Accountability Act HIPAA and its implementing regulations to be used to authorize the release of health information needed for litigation in New York State courts. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE MENTAL HEALTH TREATMENT except psychotherapy notes and CONFIDENTIAL HIV RELATED INFORMATION only if I place my initials on the appropriate line in Item 9 a. In the event the health information described below includes any of these types of information and I initial the line on the box in Item 9 a I specifically authorize release of such information to the person s indicated in Item 8. 2. If I am authorizing the release of HIV-related alcohol or drug treatment or mental health treatment information the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization* If I experience discrimination because of the release or disclosure of HIV-related information I may contact the New York State Division of Human Rights at 212 480-2493 or the New York City Commission of Human Rights at 212 306-7450. These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization* 4. I understand that signing this authorization is voluntary. My treatment payment enrollment in a health plan or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

Please sign exactly as name ap... MC-ASSIST 1-800-MC-ASSIST 1-800-MC-ASSIST 1-800-MC-ASSIST 1-800-MC-ASSIST 1-800-MC-ASSIST 1-800-MC-ASSIST 1-800-MC-ASSIST 1-800-MC-ASSIST 1-800-MC-ASSIST 1-800-MC-ASSIST 1-800-MC-ASSIST 1-800-MC-ASSIST

Release of interest 2005 form RELEASE OF INTEREST 46-0306 R03/05 www. azdot. gov I certify that I did not purchase nor did I take possession or ownership of nor do I have any interest in the vehicle described below. Vehicle Identification Number Year Make Name first middle last suffix Street Address City State Signature Notary or MVD Agent Signature Acknowledged before me this date.

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