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Request to rescind Request for Disclosure

  1. Burleson - City - Solid -Maroon
  2. Request to rescind Request for Disclosure
  3. By checking the box below, I request the City of Burleson remove my previous authorization for disclosure of information related to the account referenced below.

  4. Account information
  5. By electronically signing this form, I attest that I am the authorized account holder of the above account.
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  7. This field is not part of the form submission.