OPROB 11H (Rev. 5/03) AUTHORI ZAT ION TO REL EASE GOVERNMENT (STATE OR FEDERAL) I NFORMATI ON TO PROBATION OFFICER I, , the undersigned, hereby waive my rights under the Privacy Act, 5 U.S.C. 552a (Supp. IV, 1974), and authorize the disclosure to the United States Probation Office of the District of , or its authorized representative(s) or employee(s), any and all information pertaining to me, contained in the files or systems of records maintained by any government agency subject to the Privacy Act, which such agency sees fit to convey, either orally or in writing, to the aforementioned Probation Office. I hereby waive any rights I may have under the Privacy Act to prior notice of such disclosure, or of any rights I may have to an accounting of such disclosure to the aforementioned Probation Office. I understand that this authorization will be used by the aforementioned Probation Office to request dis- disclosure of information pertaining to me from any or all federal or state agencies. This information is to be obtained for the purpose of conducting a presentence investigation and making a report or for supervision. Regarding protected health information, I understand that this authorization is valid until my release from supervision, at which time this authorization to use or disclose this information expires. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. Regarding protected health information, I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the programs privacy contact at: (Name and Address of Program) Regarding protected health information, I understand that if I revoke this authorization to release confidential information, I will thereby revoke my authorization to further disclosure of such information. I also understand that revoking this authorization before I satisfy the condition of my supervision that requires this information will be reported to the court. My revocation of authorization under such circumstances could be considered a violation of a condition of my post-conviction supervision. Authorizing Signature (full name) Full Name (printed or typed) Date Parent/Guardian Signature, if Required Attorney Signature, if Available WITNESS Probation Officer Date