CALHOUN COUNTY ROAD COMMISSION

13300 Fifteen Mile Road • Marshall, Michigan 49068

Phone (269) 781-9841 (800) 781-5512 Fax (269) 781-8223

AUTHORITY TO RELEASE INFORMATION

I/we hereby grant authority to the Calhoun County Road

Commission Permit Department and/or staff to release information
regarding my/our address to the person/organization listed below.

Homeowner: _______________________________________

Current Address: ____________________________________

_____________________________________

Signature of Homeowner Date

Person/Organization:
____________________________________

Address: ____________________________________

____________________________________

Phone/Fax #: __________________ ________________

Signature of Person/Organization Date

Releaseform/elc/9/29/2006