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EVERGREEN LEGAL. SERVICES <br />SNOHOMISH COUNTY OFFICE <br />401 CENTRAL BUILDING <br />1721 HEWI7T AVENUE <br />EVERETT. WASHINGTON 98201 <br />ADA SHEN-JAFFE 1 1800) 822.0225 <br />DIRECTOR (206) 259'3421 <br />AUTHORIZATION TO DISCLOSE INFORMATION <br />I authorize the — `i <br />to disclose any records requested, including medical <br />records to ���to>>, ��s — or any other <br />attorney or paralegal from EVERGREEN LEGAL SERVICES, <br />1721 Hewitt, Avenue, Everett, WA 93201. <br />----1—further aut7l—orize iise-of-a p ocopv of rFiis -- - <br />authorization in lieu of an original. <br />DATED: AlAt?CF1 Ik) 1990 <br />\7s +4�j h1'; & <br />NAME <br />639-44-513`l <br />SOCIAL SECURITY NUMBER <br />ADDRESS <br />Evt­'�Z'ar, 11A 98ao <br />TELEPHONE OR MESSAGE NUMBER <br />