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.

Name:__________________________

Email Address :__________________

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.

Signed: ___________________________

Date: _____________________________

Please print this form and return completed to my District Office at:

Or fax to (205) 969-3958