PRIVACY ACT RELEASE
please print
County:____________________ Date:_________________________
Constituent's Name:__________________________________________________________
Mailing Address:____________________________________________________________
City:____________________________ State:__________ ZIP:______
Social Security Number:_________________ Any Other Identification Numbers:_____________
Daytime Telephone Number:_____________________________________________________
Date of Birth:_________________________________________________________________
Spouse's Name:_______________________________________________________________
DESCRIPTION OF INQUIRY OR CLAIM
What agency do you want Congressman Burton to contact?
What steps have you taken to resolve your issue with this agency?
Attach the most recent correspondence from the agency to this form.
Briefly describe the problem or question you want Congressman Burton to inquire about on your behalf:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
(Continue on back if necessary)
Pursuant to the Privacy Act, I (print your name) _____________________________________ give my personal and authorized consent to Congressman Dan Burton, or his designated staff representative, to make proper inquiry on my behalf to the appropriate agency.
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Constituent's Signature Date