Request for Classified Data

2. About This Request
   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.

   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.

4. 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.

   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.

6. Subject Authorization
   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.

   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.

8. First Name*

9. Last Name*

11. Email address*

12. Phone Number*

13. Date*
    Date

    Date

15. Address*

17. City*

18. State*

19. Zip Code*

21. Information Requested*

    Please be as specific as possible.

23. 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.

25. Certification*

    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 must be received in paper form, signed by the data subject, before any data can be released to me.

    1. I have read the Certification information and agree.
27. Example
    Informed Consent to Release Private Data (PDF)

    This is the form we would send to and require from anyone whose private information is the subject of your request, other than yourself. You do not need to fill it out.

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29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field