Richard G. Lugar, United States Senator for Indiana - Casework Form
Authorization Form
In accordance with the 1974 Privacy Act

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Name:__________________________________

Address:________________________________

Daytime Phone:__________________________

Evening Phone:___________________________


Social Security Number: _______-____-______

Other Cases/ID Numbers:
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Please include any other relevant identification numbers used by an agency:
(i.e. civil service, worker's compensation)

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Please write a statement concerning the specific information you are requesting or the exact
nature of the problem you encountering. Please also indicate if you are working with an attorney.

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Signature:_______________________________


Date:_____________________________

Please Return to:

Senator Richard Lugar
1180 Market Tower Building
10 West Market Street
Indianapolis, IN 46204-2964
317-226-5555