Attachment J-6 Privacy Act Waiver.pdf
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- Solicitation number
- 9594CS26Q0004
About this file
This document is a Privacy Act Waiver form issued by the Court Services and Offender Supervision Agency for the District of Columbia (CSOSA).
The form is a template that authorizes CSOSA to disclose an individual's information to specified recipients for stated purposes, in compliance with 5 U.S.C. § 552a(b). The form requires completion of three key fields: the information to be disclosed, the recipient(s) of that information, and the purpose of disclosure. The signatory must declare under penalty of perjury that the information provided is true and correct, and the form must be executed with the date and the individual's signature. The document is identified as CSOSA-OGC-0005 with a revision date of August 2008, and includes options to print or reset the form.
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Text version
Court Services and Offender Supervision Agency for the District of Columbia
CSOSA-OGC-0005 Revision: August 2008
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 ______________, 201_.
Signature
Attachment J-6
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