Consent to Release of Information
Title/Full Name
Pursuant to 5 U.S.C. ' 552a(b), The Privacy Act, I, , consent to
the release of my name and address to the National Fallen Firefighters Foundation or the Concerns of
Police Survivors, Inc. I authorize release to:
‘
Concerns of Police Survivors, Inc. (COPS)
‘
National Fallen Firefighters Foundation (NFFF)
____________________________________
______________________
(Claimant=s Name)
Date Signed
Signature
____________________________________
______________________
(Claimant=s Name)
Date Signed
Signature
Mail to:
Public Safety Officers’ Benefits (PSOB) Office
Bureau of Justice Assistance
810 7th Street, NW
Washington, DC 20531