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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 __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ What steps have you taken
so far? If possible, please include the name of the __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
What have been the results of your efforts to date? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
What would you consider a fair outcome? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
Thank you.
Please return this form to: Fax: (609) 750-0618 |
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