Letter For Release Of Information

Here is a sample template you can use to write a letter for release of information.

[Recipients Name]

[Address line]

[State, ZIP Code]

[Subject: Normally bold, summarizes the intention of the letter] -Optional-

Dear [Recipients Name],

I hereby declare that I [Name of Sender] allow the [Name of the institution] to release my information about [What is the Information About] to [Name of the Person]. I also give [Name of the Person] to use that information for [List Purposes] purposes. However, I do not permit re-disclosure of the information provided in any way. 

If you need any additional information from me, feel free to contact me directly. I am looking forward to your reply. 


[Senders Name]

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