Waiver form

Each claimant must sign a waiver. The department will not process unsigned claims and may, at any time, require claimants to sign additional waivers. The waiver statement shall read as follows:
I declare and affirm under the penalties of perjury that this claim has been examined by me, and to the best of my knowledge and belief, is in all things true and correct. I authorize any person holding any official social security records, official public aid records, official Veterans Administration records, or any other records containing information relative to the determination of the amount of this claim or my eligibility therefor to disclose the information contained on those records to the department.