Financial Authorization Letter for Financial Assistance

James P. Reynolds
321 Cedar Lane
Austin, TX 78701
(555) 678-1234
[email protected]
Date: October 16, 2024

To:
Texas Department of Social Services
Financial Assistance Division
1000 Main Street
Austin, TX 78701

Subject: Authorization to Act on My Behalf for Financial Assistance Matters

Dear Financial Assistance Officer,

I, James P. Reynolds, hereby authorize Lisa M. Reynolds to act on my behalf regarding matters related to my financial assistance application due to my current health issues. This authorization specifically grants Lisa M. Reynolds permission to manage, submit, and receive any documents or funds associated with my application for state aid.

Authorized Person’s Details:

• Full Name: Lisa M. Reynolds
• Relationship to Authorizer: Spouse
• Address: 321 Cedar Lane, Austin, TX 78701
• Phone Number: (555) 123-4567
• Email Address: [email protected]

Scope of Authorization:

I authorize Lisa M. Reynolds to:

• Access and discuss my application status with the Texas Department of Social Services
• Submit required documentation on my behalf
• Receive checks, deposits, or any financial disbursements related to my application
• Communicate with representatives of the Texas Department of Social Services for any necessary follow-up

Details of Financial Assistance:

• Agency/Program Name: Texas Department of Social Services – State Aid Program
• Case Reference Number: TXAID12345
• Type of Assistance: State Financial Aid for Medical Expenses

Duration of Authorization:

This authorization is effective from October 16, 2024, and will remain valid until December 31, 2024, or until revoked by me in writing.

Terms and Conditions:

This authorization is limited to actions directly related to my financial assistance case with the Texas Department of Social Services. Lisa M. Reynolds is authorized to perform only the actions specified above, and I retain the right to revoke this authorization at any time by providing written notice to both Lisa M. Reynolds and the Texas Department of Social Services.

For any additional verification or questions, please contact me at (555) 678-1234 or [email protected].

Signature of Authorizer: ___________________________
Printed Name: James P. Reynolds
Date Signed: October 16, 2024

Signature of Witness (if required): ___________________________
Printed Name of Witness: Sarah T. Johnson
Date Signed: October 16, 2024

Notary Public Signature (if required): ___________________________
Notary Seal: ___________________________
Date: October 16, 2024

Thank you for your assistance in processing this authorization.

Sincerely,
James P. Reynolds.