HomeMy WebLinkAboutconsent-release-of-conf-scanned-copiesSend Completed Form via SECURE e-mail Homestretch@acgov.org or FAX to 1(855) 658-5466
Revised 10/21/2025
Consent for the Release of:
Confidential Scanned Copies of Personal Identification Documents
to Alameda County Health – Home Stretch
Client Name:
Client Date of Birth: Client Social Security Number:
The service provider currently helping me find permanent housing is:
Service Provider Name: Name of Agency and Program:
E-mail Address: Phone #:
Alameda County Social Services Agency (SSA) system of records: 1. Social Security Number 2. Date of Birth 3. Income Verification detailing monetary benefits issued by Alameda County (ex. CalWORKs, General Assistance). For more information about applying for benefits and/or viewing existing benefit details, go to: www.benefitscal.com 4. Verification of other cash benefits that share data with Alameda County; often this includes Federal benefits, such as SSI/SSP/RSDI, unemployment, or disability benefits . NOTE: SSA cannot guarantee the accuracy of information about benefits issued by entities other than Alameda County. Award letters directly from the entity issuing the benefit will always be most accurate.
(Optional) I would like the following information from the list above to NOT be included in my letter:
Upon request, these added details can be added to the standard verification letter. (CHECK ALL THAT APPLY):
Other Social Services program enrollment details (CalFresh, Medi-Cal, etc.)
Confirmation of Citizenship Status. Upon request, this detail can be added to the standard verification letter.
If there are copies of identity documents on file that can be sent with this letter, please also include (CHECK ALL THAT APPLY):
Government issued photo ID
Social Security Card
Birth Certificate
I authorize the Alameda County Social Services Agency Workforce and Benefits Administration Department to release information requested above to me, Home Stretch staff, and to my current service provider. These documents will be used to help me obtain housing/housing resources. This form is valid for a single request of records. A new form must be signed each time a new verification letter is needed and/or if the signature
on the form is dated more than 12 months ago.
Signature of Client: Date:
Signature of person signing form if not client: Date:
Describe authority to sign on behalf of client: _________________________________________ *A Service Provider can ONLY sign on behalf of their client is if the client cannot provide a signature for themselves (including but not limited to if the client is hospitalized or incarcerated) and gives the signing service provider permission to sign on their behalf.