Request Financial Assistance

In consideration of the services to be undertaken or rendered on my behalf by the Society of St. Vincent de Paul, its members, agents or affiliated organizations (hereinafter referred to as "SVdP", I, the undersigned hereby authorize SVdP to receive, from any and all sources, and to release to any person or organization, any confidential information regarding me which may be necessary or useful to SVdP in relation to the services to be rendered.

I hereby release SVdP from all liability in any way related to the receipt and/or release of said confidential information. I further understand that the release of this information does not guarantee that assistance will be provided. but that without such information my case cannot be considered. This release expires sixty (60) days after the Undersigned signature date.