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CASEWORK AUTHORIZATION TO REVIEW PERSONAL
INFORMATION PROTECTED BY THE PRIVACY ACT
(The Privacy Act requires that you authorize access to your private records. Without your authorization, an inquiry on your behalf will not be possible.)

Date: ___________________

I have asked U.S. Representative Judy Biggert to communicate with (list Federal agency) __________________________________________ on my behalf. In order to respond to her inquiry about me and to giver her status reports on my case, I realize that it may be necessary to release information about that, under the Privacy Act of 1974 (Public Law 93-579) cannot be released without my written consent. This form is to serve as my consent for the release of such information to Congresswoman Biggert or her designee.

Signature: __________________________________________

Name (printed): __________________________________________

Address: __________________________________________

__________________________________________

Phone (Home): __________________________________________

Phone (Work): __________________________________________

Social Security Number or __________________________________________
Alien Number (if INS case)

Please add the following information
ONLY for Internal Revenue Service cases:

Type of Tax (income, employment, etc.): ___________________________________

Tax Year(s) or Tax Period(s): ___________________________________

Briefly explain the problem. Attach copies of any relevant documentation.

___________________________________________________________________

PLEASE RETURN THE COMPLETED FORM, and copies of any accompanying documentation to:

The Honorable Judy Biggert
6262 S. Route 83, Suite 305
Willowbrook, Illinois 60527
Fax: (630) 655-1061