Release of Information Form
This is a consent for release of information (hereinafter referred to as the “Release of
Information”) about:
_______________________________________________________________________
Name of Individual
_____________________________
_____________________________
Social Security Number
Date of Birth
I authorize __________________________ to release or obtain (circle one) the following
specific information:
_______________________________________________________________________
_______________________________________________________________________
This information may be used only for the following purposes:
_______________________________________________________________________
_______________________________________________________________________
This Release of Information is valid until __________________________. This Release
of Information is not automatically renewable. It expires automatically at the end of the
period specified unless revoked in writing sooner.
I understand I have the right to see this information at any time. I understand that I can
revoke this consent in writing to both the person giving and the person receiving the
information. Any information already released may be used as stated on the consent. By
my signature below, I affirm that I have read this release or it has been read to me, and I
understand its content.
_________________________________
_________________________________
Individual’s Printed Name
Witness Printed Name
_________________________________
_________________________________
Individual’s Signature
Witness Signature
_________________________________
_________________________________
Date
Date
©
TEMPLATEROLLER.COM
Release of Information Form
This is a consent for release of information (hereinafter referred to as the “Release of
Information”) about:
_______________________________________________________________________
Name of Individual
_____________________________
_____________________________
Social Security Number
Date of Birth
I authorize __________________________ to release or obtain (circle one) the following
specific information:
_______________________________________________________________________
_______________________________________________________________________
This information may be used only for the following purposes:
_______________________________________________________________________
_______________________________________________________________________
This Release of Information is valid until __________________________. This Release
of Information is not automatically renewable. It expires automatically at the end of the
period specified unless revoked in writing sooner.
I understand I have the right to see this information at any time. I understand that I can
revoke this consent in writing to both the person giving and the person receiving the
information. Any information already released may be used as stated on the consent. By
my signature below, I affirm that I have read this release or it has been read to me, and I
understand its content.
_________________________________
_________________________________
Individual’s Printed Name
Witness Printed Name
_________________________________
_________________________________
Individual’s Signature
Witness Signature
_________________________________
_________________________________
Date
Date
©
TEMPLATEROLLER.COM
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LATEST UPDATES
OF 122C-A - Transfer Order - Computers for Learning Program - Continuation Sheet - Created - 9/30/2022
OF 122C - Transfer Order - Computers for Learning Program - Created - 9/29/2022
GSA 7437 - Art In Architecture Program - National Artist Registry - Revised and Renewed - 9/28/2022
GSA 2419 - Certification of Progress Payments Under Fixed-Price Construction Contracts - Renewed - 9/27/2022
GSA 850 - Contractor Information Worksheet - Renewed - 9/27/2022
GSA 1789B - Former President's International Mail - Canceled - 9/22/2022
GSA 1789A - Former President's Domestic Mail - Canceled - 9/22/2022
SF 1418 - Performance Bond for Other than Construction Contracts - Renewed - 8/31/2022
SF 1416 - Payment Bond for Other than Construction Contracts - Renewed - 8/31/2022
SF 1415 - Consent of Surety and Increase of Penalty - Renewed - 8/31/2022
SF 1414 - Consent of Surety - Renewed - 8/31/2022
SF 275 - Reinsurance Agreement in Favor of the United States - Renewed - 8/31/2022
SF 274 - Reinsurance Agreement for a Bonds Statute Payment Bond - Renewed - 8/31/2022
SF 273 - Reinsurance Agreement for a Bonds Statute Performance Bond - Renewed - 8/31/2022
SF 35 - Annual Performance Bond - Renewed - 8/31/2022
SF 34 - Annual Bid Bond - Renewed - 8/31/2022
SF 25B - Continuation Sheet for Standard Forms 24, 25, and 25A - Renewed - 8/31/2022
SF 25A - Payment Bond - Renewed - 8/31/2022
SF 25 - Performance Bond - Renewed - 8/31/2022
SF 24 - Bid Bond - Renewed - 8/31/2022
GSA 2957PD - Reimbursable Work Authorization (Real Property Utilization and Disposal) - Revised - 8/23/2022
GSA 2957 - Reimbursable Work Authorization - Revised - 8/23/2022
OF 301B-M - Volunteer Service Agreement - Natural and Cultural Resources - Volunteer Sign-up Form for Groups (Mandarin) - Created - 8/17/2022
OF 301A-M - Volunteer Service Agreement - Natural and Cultural Resources (Mandarin) - Created - 8/17/2022
OF 301-M - Volunteer Service Application - Natural and Cultural Resources (Mandarin) - Created - 8/17/2022
OF 301B-S - Volunteer Service Agreement - Natural and Cultural Resources - Volunteer Sign-up Form for Groups (Spanish) - Created - 8/17/2022
OF 301A-S - Volunteer Service Agreement - Natural and Cultural Resources (Spanish) - Created - 8/17/2022
OF 301-S - Volunteer Service Application - Natural and Cultural Resources (Spanish) - Created - 8/17/2022
GSA 1260 - Security Resolution Certificate for Fire Alarm Communicators - Revised - 8/3/2022
SF 1424 - Inventory Disposal Report - Revised - 7/20/2022
SF 1423 - Inventory Verification Survey - Revised - 7/20/2022
SF 1429 - Inventory Disposal Schedule - Continuation Sheet - Renewed - 7/1/2022
SF 1428 - Inventory Disposal Schedule - Renewed - 6/30/2022
SF 1443 - Contractor's Request for Progress Payment - Revised - 6/2/2022
SF 1449 - Solicitation/Contract/Order for Commercial Products and Commercial Services - Revised - 6/2/2022
GSA 7501 - Internal Control Audit Tracking System (ICATS) Access Request - Revised - 6/2/2022
SF 1444 - Request for Authorization of Additional Classification and Rate - Renewed - 6/1/2022
SF 1413 - Statement and Acknowledgment - Renewed - 6/1/2022
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