Authorization for Release of Records

 

To: United States Department of Agriculture
Natural Resources Conservation Service

 

I hereby authorize the release of my individual records that are in the custody of the United States Department of Agriculture, Natural Resources Conservation Service.

I authorize release of records to the following named individual(s) or representative(s) of the following organization(s):

List Names(s) or Organization(s)Example: Erie County Department of Planning, c/o Robert Banks

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I authorize release of the following information:Any information in my filesOnly the following information as noted below

Beginning date for the release of records

Ending date for release of records

I understand and acknowledge that NRCS cannot be responsible for ensuring the confidentiality of released records.

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Date Signed *

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