Permission to Access DTA Client Record: English, Spanish & Haitian Creole

Below a SAMPLE consent statement - in English, Spanish and Haitian Creole - that helping agencies can use in order to speak with DTA about a specific case record or get copies of documents in the case record. This statement can be mailed or faxed to DTA, or uploaded to the client's DTAConnect account. 

A client can also hand write the same information on a blank piece of paper that gives written permission or consent for a helping agency or individual to speak with DTA. A typed up form is not required. (Exceptions apply for victims of domestic violence (who may have heightened security protection on their SNAP or cash assistance cases). 

Verbal consent: A client can also give DTA a verbal consent to a helping agency. The helping agency can arrange a three-way conference call with the client and DTA, where the client can confirm their identity and consent over the phone to the DTA worker.

A note about Authorized Representatives: Individuals who are acting on behalf of and/or financially managing the SNAP or cash benefits of an elder or disabled household will be need to sign a different DTA form called a "Request to Choose Someone to Be My Authorized Representative" (Image 10 form). Agencies serving as authorized representatives need to complete the Image 10 form.  DO NOT confuse the Authorized Rep form with a Consent to talk with DTA statement.