Attachment J-7 Release of Information-Privacy Act Waiver.pdf
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- Attached to
- Residential Drug Treatment Services
- Solicitation number
- 9594CS26Q0055
About this file
This is a Privacy Act Waiver form used by the Court Services and Offender Supervision Agency for the District of Columbia (CSOSA).
The form, designated CSOSA-OGC-0005 (Revision: August 2008), serves as a template for individuals to provide prior written consent for the disclosure of their personal information held by CSOSA. The document authorizes CSOSA to release specified information to designated recipient(s) for stated purposes, with the disclosure authority derived from 5 U.S.C. § 552a(b). The form includes three blank sections for the individual to specify: (1) the information to be disclosed, (2) the recipient(s) of that information, and (3) the purpose of disclosure. The signatory must declare under penalty of perjury that the information provided is true and correct, and must execute the form by providing their signature, the day, month, and year of execution. The form includes "Print Form" and "Reset Form" functionality options at the bottom.
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Text version
Court Services and Offender Supervision Agency for the District of Columbia
CSOSA-OGC-0005 Revision: August 2008
Attachment J-7: 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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