Survivor’s Track-Kit Barcode Number or Other Unique Identifier:	Date of Birth:
Offense County:	Offense Date:

Release Evidence to Law Enforcement for Investigation

I am choosing to report the sexual assault to law enforcement. By doing so, I give permission to the Texas Department of Public Safety to release evidence collected and information documented during my sexual assault examination and treatment to the law enforcement agency listed below for use in investigating the assault or prosecuting the assailant.

Law Enforcement Agency Information (if applicable)

Agency	Criminal Incident Report Number
Agency Contact
Agency Address	City, State, Zip
Business Email	Phone	Fax

ACKNOWLEDGEMENT OF UNDERSTANDING

I understand that I have the right to release the evidence to law enforcement for investigation at any time prior to the evidence destruction. Following five years after the collection date, the evidence will be destroyed if I have not requested that it be released to law enforcement.

I understand that I may withdraw the consent for release at any time by notifying the Texas Department of Public Safety in writing. The withdrawal is effective on the date it is received and has no effect on any actions previously taken prior to the consent for release withdrawal.

I understand that a photocopy or fax of this form is the same as the original.

Survivor Acknowledgement:

Printed Name (pseudonym acceptable)	Signature	Date

Authorized Representative Acknowledgement:

Court-Appointed Guardian / Conservator	Other Legal Representative

Printed Name	Signature	Date

Send completed form to:

Texas DPS Bio-Warehouse

12230 West Road, Building C

Houston, TX 77065

Email: HoustonCrimeLab@dps.texas.gov