Form Ps 6c - Authorization To Release Financial Information To Pretrial Services Officer
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2PS 6C
(10/88)
AUTHORIZATION TO RELEASE FINANCIAL INFORMATION
TO PRETRIAL SERVICES OFFICER
(Bank or Other Financial Institution)
Name and Address of Financial Institution
I,
, having read the explanation
(Name of Customer)
of my rights on the reverse side of this form, hereby authorize the disclosure of the following financial records:
to
, an officer of the United
(Name of Pretrial Services Officer)
States District Court for the
,
(Name of District Court)
I hereby direct you to release such information. This release is executed with full knowledge and under-
standing that the information is for the United States Pretrial Services Office’s official use.
I hereby release you, as custodian of such records, your officers, employees, or related personnel, both
individually and collectively, from any and all liability for damages of whatever kind which may at any time
result to me, my heirs, family, or associates because of compliance with this authorization and request for
information or any other attempt to comply with it.
The information hereby obtained by the aforementioned pretrial services office is to be used only for the
purpose of pretrial services investigation and report and, if applicable, for supervision.
I understand that this authorization may be revoked by me in writing at any time before my records, as
described above, are disclosed, and that this authorization is valid for no more than three (3) months from the
date of my signature. I understand further that my authorization cannot be required as a condition of my doing
business with the above named financial institution.
Date
Signature of Customer
Address of Customer
City, State, Zip Code
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