Teen Court Volunteer's Authorization to Release Confidential Information

Date: _______________

To: ____________________________

______________________________________________________________

_____________________________________________________________

Dear _______________,

You are hereby authorized and requested to mail or deliver to:

________________________________

Name

_____________________________________________________________________

Address

Either original or copies of the below described documents or confidential information that you may have in your possession. You may bill me for any costs associated with your compliance with this request and I thank you for your cooperation.

Very truly,

___________________________ ______________________________

Signature Print Name

___________________________________________________________________

Address

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