"Consent to Release Information" - New York City

Consent to Release Information is a legal document that was released by the New York City Department of Housing Preservation and Development - a government authority operating within New York City.

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Consent to Release Information 
 
I/we, ______________________________, consent to the release of records or information on my 
behalf to the entities or party below on this form: 
1. I/we request that the New York City Department of Housing Preservation and Development (HPD), 
Division of Tenant Resources (DTR), release information related to my DTR case file, if available, to the 
person or entity listed below, who has submitted a request for information on my case:  
 
______________________________________    
 
__________________________  
(Organization/Name)   
 
 
 
 
 (Phone)  
 
______________________________________    
 
__________________________  
(Address)  
 
 
 
 
 
 
(Email)   
2. I/we release HPD from all claims or causes of action arising out of or related to HPD’s release of 
records to the above‐named person or entity.  
3. I/we acknowledge that I/we have read this consent form and fully understand it.  
4. I/we acknowledge that this consent form may not be changed orally, and that this consent form will 
automatically expire in 180 days from the date listed below. 
 
______________________________ 
Name (Please print) 
______________________________    
 
Signature 
_______________  
Date  
 
(Requests missing any information cannot be honored) 
Consent to Release Information 
 
I/we, ______________________________, consent to the release of records or information on my 
behalf to the entities or party below on this form: 
1. I/we request that the New York City Department of Housing Preservation and Development (HPD), 
Division of Tenant Resources (DTR), release information related to my DTR case file, if available, to the 
person or entity listed below, who has submitted a request for information on my case:  
 
______________________________________    
 
__________________________  
(Organization/Name)   
 
 
 
 
 (Phone)  
 
______________________________________    
 
__________________________  
(Address)  
 
 
 
 
 
 
(Email)   
2. I/we release HPD from all claims or causes of action arising out of or related to HPD’s release of 
records to the above‐named person or entity.  
3. I/we acknowledge that I/we have read this consent form and fully understand it.  
4. I/we acknowledge that this consent form may not be changed orally, and that this consent form will 
automatically expire in 180 days from the date listed below. 
 
______________________________ 
Name (Please print) 
______________________________    
 
Signature 
_______________  
Date  
 
(Requests missing any information cannot be honored)