|Privacy Release Form|
Due to the enactment of the "Right to Privacy Act," it is necessary for you to complete and sign this form authorizing me and members of my staff to obtain the information needed to respond to your request for assistance. The information obtained will be only that which is relative to the problem you presented to my office.
Email Address :__________________
City:___________________________State:_____ Zip Code:_______
Phone (home): ( ) _____-______ (work): ( )_____ -______
Social Security Number: _____-_____-_____
Date of Birth: _____________
I understand that in order for you to respond fully to my request, it may be necessary for you or your staff to review those federal records that contain information you will need to assist me. By signing this form, I hereby authorize the appropriate federal agencies to release to you such information as you may require.
Please print this form and return completed to my District Office at:
Or fax to (205) 969-3958