ARSD § 64:47:02:14 — Waiver form

Each claimant must sign a
waiver. The department may not process unsigned claims and may, at any time,
require claimants to sign additional waivers. The waiver 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.