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PRIVACY RELEASE FORM
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:__________________________
Address:________________________
City:___________________________
State:__________
Zip Code:_______
Email
Address :__________________
Phone
(home): ( ) _____-______
Phone
(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:
_____________________________
Description of your
situation:___________________________________________________
___________________________________________________________________________
__________________________________________________________________________
Please print this form and return completed to my District
Office at:
Congressman Tim Ryan
197 West Market
Street
Warren, Ohio
44481
Phone: (330) 373-0074 Fax: (330) 373-0098
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