Sample Investigation Consent Form printable pdf download

Sample Consent Form

(Must be on the investigating agency or department letterhead)

I, "XYZ", being duly sworn, on this [insert date] do hereby state the following:

I have one or more profiles on .

The URLs / FriendIDs are:

______________________________________________________________________

I understand that the "XXXX" agency is conducting an official criminal investigation and has

requested that I grant my consent to authorize the "XXXX" agency to access, request, receive,

review, copy and otherwise utilize, as they deem appropriate, the following information from

the above profiles: [specify information sought]

I hereby authorize to provide to any agent of the above referenced agency, the

above-specified information associated with my identified profiles/accounts.

The following information should be used to verify my identity:

Email address for account: ___________________________________________________

Password for account: ________________________________________________________

Date of birth on account: _____________________________________________________

Zip Code for account: __________________________________________________________

Pursuant to this Consent, I waive any claims against, indemnify and hold harmless

, its affiliates, and their respective directors, officers, agents, and employees from

and against any claims, damages or expenses relating to or arising from, in whole or in part, the

disclosure of such information, records and data.

I have not been promised anything in exchange for providing this consent and authorization.

In witness whereof, the undersigned makes the above statements under penalty of perjury.

________________________________________

________________________

Member Signature

Date

_________________________________________________

Printed Name

______________________________

_____________________

Law Enforcement / Witness Signature

Date

____________________________________________________

Printed name and title

Sample Investigation Consent Form