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Date (don't forget this)

To whom it may concern, (or the name and organization of a specific party if applicable)

I authorize (name of person authorized) to get (item/document requested) on my behalf. If there are any questions about releasing this (item/document), you may contact me at (phone number or email address).

Sincerely

Signature

Type or print name

Note: Don't forget to include any dates that might limit the period of your authorization, if applicable (unless this is a permanent or open ended authorization).

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12y ago

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