Attachment J-5 Release of Information-Privacy Act Waiver.pdf
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- Attached to
- Outpatient Treatment Services
- Solicitation number
- 9594CS26Q0003
About this file
This is a Privacy Act Waiver form (Attachment J-5) issued by the Court Services and Offender Supervision Agency for the District of Columbia. The form template is used to obtain an individual's prior written consent for the disclosure of their personal information in accordance with 5 U.S.C. § 552a(b). The form requires the signatory to provide their name and authorize CSOSA to disclose specific information to designated recipient(s) for a stated purpose. Three blank sections must be completed: the information to be disclosed, the recipient(s) of that information, and the purpose of disclosure. The form includes a declaration under penalty of perjury affirming the accuracy of the provided information, with spaces for the date of execution and the individual's signature. The document is identified as CSOSA-OGC-0005, revised in August 2008, and includes print and reset form functionality options.
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Court Services and Offender Supervision Agency for the District of Columbia
CSOSA-OGC-0005 Revision: August 2008
Attachment J-5: RELEASE OF INFORMATION PRIVACY ACT WAIVER
I, ________________________________________________ [Name], hereby authorize and give my prior written consent pursuant to 5 U.S.C. § 552a(b) to the
Court Services and Offender Supervision Agency for the District of Columbia, to disclose the information noted below concerning me to the recipient(s) noted below for the purpose noted below.
Information to be disclosed:
Recipient(s):
Purpose of disclosure:
I declare under penalty of perjury that the foregoing is true and correct.
Executed this ______ day of ______________, 202_.
Signature
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