Law Enforcement DNA Sample Release Permission

Name of Individual Providing Permission:
Relationship to Subject (if applicable):
Address:
Phone Number:
Subject Name (whose DNA sample is being released):
Date of Birth:
Case/Reference Number:
Agency/Organization Requesting DNA Sample:
Purpose of DNA Sample Release:
Description of DNA sample/material to be released:
Additional Comments/Restrictions (if any):

I hereby authorize the release of the above-specified DNA sample/material to the listed agency/organization for the stated purpose.

Signature
Date:
Witness Signature
Date: