Legal Case Information Release Authorization

Case Name:

Case Number:

Court/Jurisdiction:

Person Authorizing Release

Full Name:

Relationship to Case:

Contact Information:

Information to be Released

Recipient of Information

Name/Organization:

Contact Information:

I hereby authorize release of the above-identified case information to the recipient listed. I understand this authorization is voluntary and may be revoked in writing at any time.

Signature:

Date:

Witness (if required):

Date: