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[]
[null,"Authorization to Release Information"]
[]
["Client Name:"]
["Social Security #:"]
["Address:"]
["Phone:"]
[]
["I hereby authorize the below listed company to provide and release income information to SNAP:"]
[null,null,null,null,null,"2017-09-15"]
[null,"Signature of Applicant",null,null,null,"Date"]
["**Employer provides below information** "]
["Company Name:  "]
["Company Address:"]
[]
["**Information must be exact Gross Income, not net or estimated** "]
[null,"For the months of:",null,"2017-06-15","2017-07-16","2017-08-16"]
["Pay Date:",null,"Amount:",null,null,"Pay Days are Normally:"]
["Pay Date:",null,"Amount:"]
["Pay Date:",null,"Amount:",null,null,"__Every __________"]
["Pay Date:",null,"Amount:",null,null,"__Every Other_____"]
["Pay Date:",null,"Amount:",null,null,"__The __ and the __"]
["Pay Date:",null,"Amount:"]
["Pay Date:",null,"Amount:",null,null,"Is this taxed?____"]
["Pay Date:",null,"Amount:"]
["Pay Date:",null,"Amount:"]
["Pay Date:",null,"Amount:"]
["Pay Date:",null,"Amount:"]
["Pay Date:",null,"Amount:"]
["Pay Date:",null,"Amount:"]
[]
["Information Provided by:"]
["Name & Title:"]
["Phone Number:"]
["Date:"]
[]
["Please Return to:"]
[null,null,"SNAP"]
[null,null,null,"Phone","509-456-7627 x"]
["Spokane WA 992xx",null,null,"FAX"]
[null,null,null,"Email"]