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<br />~ <br /> <br /><# <br /> <br />CONSENT FOR THE RELEASE OF INFORMATION <br /> <br />I J <br /> <br />(name of individual authorizing release) <br /> <br />authorize <br /> <br />(name of Responsible Authority or city) <br /> <br />to disclose to <br />(name of individual or entity to receive the information) <br /> <br />the following information: <br /> <br />(description of the'information) <br /> <br />for the purpose of: <br /> <br />I understand that my records are protected under State and <br />Federal privacy regulations and cannot be disclosed without my <br />written consent unless otherwise provided for by law. <br /> <br />I also understand that I may cancel this consent at any time <br />prior to the information being released and that in any event <br />this consent form expires automatically 90 days after signing. <br /> <br />Signed this <br /> <br />day of <br /> <br />. 19 <br /> <br />(Signature of individual authorizing release) <br /> <br />(Signature of Witness) <br /> <br />(Mo/Day/Yr) <br />