Case Authorization & Privacy Release Form

The Privacy Act of 1974 is a Federal law designed to protect you from unauthorized use and exchange of personal information by Federal agencies. Any information that a Federal Agency has on file regarding your dealings with the United States government may not, with a few exceptions, be given to another agency or to a Senator or Member of Congress without your written permission

Please print, fill out, and return this form to either the Seattle or Spokane offices. These are the only two state offices that can initiate a request on your behalf. For the address to these offices, please click here.

I hereby request the assistance of the Office of United States Senator Maria Cantwell in resolving the matter described above and authorize Senator Cantwell and her staff to receive any information which they might need in order to provide this assistance.

Full name: _____________________________________________________

Please describe the situation with which you are requesting assistance or refer to correspondence you have already sent.

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Permanent address:

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City: ________________________ State :_ Zip:_________________

Email: _______________________________________________________________

Phone Number________________________________________________________

Social security number: ___ Date of birth:

Alien Indentification (if applicable): _____________________________________

Other claim numbers (if applicable, please specify agency):

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