Consent to Release Personal Information

CONSENT TO RELEASE PERSONAL INFORMATION

I, ______, of ______, in the Province of Ontario, SOLEMNLY DECLARE that:

1. I am the person to whom the information described below relates, born on ______.

2. I authorize ______ to release the following information or records: ______, to ______.

3. This consent is subject to the following limits or conditions: ______.

4. I give this consent freely for the following purpose: ______. This consent remains in effect until I revoke it in writing.

I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.

DECLARED before me at the ______________________ of ______________________, in the Province of Ontario, this ______ day of ______________, 20______.

_______________________________ _______________________________

A Commissioner for taking Affidavits Signature of Declarant