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**Use this packet when the case involves a forgery. This could include many documents and transactions as well.**
(name/address of account holder) to release the financial information of the individual names below:
I authorize the information to be disclosed and discussed with the Alliance Police Department, the Box Butte County Attorney's Office, or the Nebraska Attorney General's Office.
The type and amount of information to be disclosed is as follows:
Copy of signature card or similar type document showing the account holder(s) signature.
I understand this authorization will expire, without my express revocation, one year from the date of signing, or if I am a minor, one year from the date of signing or on the date I become an adult according to state law, whichever is earlier. I understand I may revoke the authorization at any time except to the extent that action has been based on this authorization. I understand the revocation must be in writing and presented to the provider named above. I understand my authorization is not needed under some conditions as previously explained pursuant to a notice received from the provider named above and any revocation in writing of this authorization does not affect the ability of the provider named above to disclose information otherwise allowed by law. I understand I have a right to a copy of this authorization.
I understand that authorization for the disclosure of this financial information is voluntary and I can refuse to sign this authorization. I understand any disclosure of information carries with it the potential for re-disclosure and the information may not be protected by federal law or regulations.
*Complete one form for EACH credit/debit card fraudulently used.
*Alliance Police Department Staff Use Only
(e.g. reported stolen, contact with the account holders, quality of document, etc....)
**BE AS DETAILED AS POSSIBLE
Complete any that are applicable
(Make, Model, Color, License Plate, etc.)
(e.g. reported as stolen, contact with account holder, quality of document, etc.) *BE DETAILED WITH YOUR EXPLANATION.
This field is not part of the form submission.
* indicates a required field