WRITTEN AUTHORIZATION UNDER THE PROVISIONS

OF THE PRIVACY ACT OF 1974

Date: __________________________

Dear Congressman Holt,

I would like to request assistance with the following problem I am having with the agency listed below.

In keeping with the restrictions of the Privacy Act of 1974, I am authorizing you and/or your staff to obtain information about me, which would be required in your investigation of the matter, outlined below.

Please Print or Type:

Mr. or Ms. (circle one) Name: _____________________________________­­­___­_________

Address: _______________________________________________________________

City: __________________________________________ ZIP: ___________________

Home Phone: ________________________ Work Phone: ________________________

Email Address: __________________________________________________________

Date of Birth: _______________ Social Security #: _____________________________

You Social Security number and date of birth are needed to obtain or discuss your records in any case with Social Security, Medicare, Veterans Affairs and other health care providers. If your issue does not pertain to one of these, I will not need this information.

Signature: _____________________________________________________

Agency the Issue Concerns: ___________________________________________

Briefly explain the nature of your complaint or concern and attach copies of
any documents you may have.

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What steps have you taken so far? If possible, please include the name of the
agency or persons you have contacted.

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What have been the results of your efforts to date?

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What would you consider a fair outcome?

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Thank you.

Please return this form to:
Rep. Rush Holt
50 Washington Road
West Windsor, New Jersey 08550

 Fax: (609) 750-0618

www.holt.house.gov