TRANSFER OF OWNERSHIP OF BANKED DNA SAMPLE

I, _____________________________________________________________________________________________________

Date of Birth: __________________________ Social Security Number: ____________________

wish to transfer ownership of and responsibility for the sample of banked DNA held in the DNA bank of Comprehensive Genetic Services, SC in Milwaukee, WI (or its designated responsible party) to:

Name:

Address:

Phone:

Signature: ___________________________________________ Date: _____________

Witness: _____________________________________________Date: _____________