Form CN4402 "Authorization for Release of Non-health Information" - Connecticut

What Is Form CN4402?

This is a legal form that was released by the Connecticut State Department of Correction - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 30, 2009;
  • The latest edition provided by the Connecticut State Department of Correction;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CN4402 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Correction.

ADVERTISEMENT
ADVERTISEMENT

Download Form CN4402 "Authorization for Release of Non-health Information" - Connecticut

769 times
Rate (4.4 / 5) 46 votes
Authorization for Release of Non-Health Information
CN 4402
REV 6/30/09
Connecticut Department of Correction
Inmate name:
Inmate number:
Date of birth:
I hereby authorize the State of Connecticut, Department of Correction and its staff at the (list facility):
To disclose the following information from my master file:
(initial)
Date(s) of admission/discharge.
(initial)
Other master file information (specify):
(initial)
To disclose the following information (specify):
(initial)
Individual/organization to receive information:
The specific purpose of this request:
I understand that this authorization is voluntary and that I may withdraw my consent at any time prior to the release
of the indicated information. My consent, if not withdrawn, will continue throughout my term of supervision by the
DOC regardless of my placement and including any time spent on parole or community supervision.
Return to (facility stamp) :
requestor signature
date
witness signature
date
parent/guardian signature
date
(if requestor is a minor)
Authorization for Release of Non-Health Information
CN 4402
REV 6/30/09
Connecticut Department of Correction
Inmate name:
Inmate number:
Date of birth:
I hereby authorize the State of Connecticut, Department of Correction and its staff at the (list facility):
To disclose the following information from my master file:
(initial)
Date(s) of admission/discharge.
(initial)
Other master file information (specify):
(initial)
To disclose the following information (specify):
(initial)
Individual/organization to receive information:
The specific purpose of this request:
I understand that this authorization is voluntary and that I may withdraw my consent at any time prior to the release
of the indicated information. My consent, if not withdrawn, will continue throughout my term of supervision by the
DOC regardless of my placement and including any time spent on parole or community supervision.
Return to (facility stamp) :
requestor signature
date
witness signature
date
parent/guardian signature
date
(if requestor is a minor)