Request for Classified Data

2. <strong>NOTICE: </strong>You may cancel this request at any time prior to the release of information. In any event, this consent form will expire 90 days after submitting.<br/><br/> After being shown private data on individuals and informed of its meaning, this data need not be disclosed again for six months unless additional information has been collected or an action is pending.<br/><br/> <strong>NOTE:</strong> The subject of the data request must authorize the release of private information to the subject’s agent or another agency. An “Informed Consent to Release” must be completed by the subject of the data.

   NOTICE: You may cancel this request at any time prior to the release of information. In any event, this consent form will expire 90 days after submitting.
   
   After being shown private data on individuals and informed of its meaning, this data need not be disclosed again for six months unless additional information has been collected or an action is pending.
   
   NOTE: The subject of the data request must authorize the release of private information to the subject’s agent or another agency. An “Informed Consent to Release” must be completed by the subject of the data.

4. First Name*

5. Last Name*

7. Email address*

8. Phone Number*

9. Date*
   Date

   Date

11. Address*

13. City*

14. State*

15. Zip Code*

17. Information Requested*

    Please be as specific as possible.

19. Fees may apply.

    You may be required to pay the actual costs of making and/or compiling data. Fees will be determined following the submission of this request.

    You may be required to pay the actual costs of making and/or compiling data. Fees will be determined following the submission of this request.

21. By submitting this form I certify that I am the subject of the data. If I am not the subject of the data I understand that an “Informed Consent to Release Form" [click here to download this form] must be received in paper form, signed by the data subject before any data can be released to me.

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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field