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I; 1; 1 103 1 V 0 11 <br />1, <br />(name of individual authorizing release) <br />authorize the (City of Elk River) (Economic Development Authority in and for the City of Elk River) <br />(Housing and Redevelopment Authority of the City of Elk River) to disclose to <br />the following information <br />(description of information) <br />for the following purpose: <br />I understand that my records are protected under state and/or federal privacy laws and cannot be <br />disclosed without my written consent unless otherwise provided for by state or federal law. I also <br />understand that I may revoke this consent at any time and that in any event this consent expires <br />automatically on 1 19. <br />Executed this day of , 19 <br />X <br />(signature of individual authorizing release) <br />I witnessed sign the above release; and s/he did so of his/her own <br />free will. <br />(signature of witness) <br />CAH50884 <br />GA115-26 <br />