AGAPE IN MOTION INCORPORATED 

CLIENT AUTHORIZATION & ACKNOWLEDGEMENT 

 

I understand that it may be necessary for Agape In Motion Incorporated (AIM) to discuss information about 
my financial situation, employment, or other personal information with representatives of other agencies as is 
necessary to make the best decisions in the interest of my personal situation. 

 

I understand that these are necessary procedures for the AIM to assist with my situation. I also understand 
that information about personal circumstances will be treated in confidence and that none of the information 
provided will be accessible to any party who is not directly involved unless prior permission is received. 

 

I authorize AIM to discuss with any other agencies information related to personal circumstances as may be 
necessary to help secure my full legal rights in attempts to improve my immediate personal situation. 

 

I further authorize AIM to release financial, employment, and other information to other agencies as may be 
essential to assist with receiving direct assistance. 

 

I understand that if any information provided by me is found to be falsified, legal action can and will be taken 
against me. 

 

My signature below indicates that I understand and authorize Agape to act in my best interest 

when requesting or sending information about my personal situation. 

Printed Name ________________________________ 

Signature __________________________________________ Date ______________ 

Witness __________________________________________ Date ______________ 

TERM: This authorization shall be effective from the date signed through TWO YEARS or 
until the client/agency relationship is terminated, whichever occurs first.