PRIVACY RELEASE AUTHORIZATION
I authorize the following agency(s) to
release information to
Congressman Peterson or his
staff concerning my request for
assistance.
Agency(s):
____________________________________________________________________
______________________________________
Signature
______________________________________
Date
Name___________________________________________________________________________
Address_________________________________________________________________________
City/State/Zip____________________________________________________________________
Daytime
Phone_____________________________ Evening
Phone_______________________
Fax
Number_____________________________________________________________________
Date
of
Birth_____________________________________________________________________
Social
Security
#__________________________________________________________________
INS
Alien
Number________________________________________________________________
VA
Claim
Number________________________________________________________________
Are
you facing a deadline? Yes / No (Circle one) Date
_____________________
Have you contacted my office before on this matter? Yes / No (Circle One)
If yes, when and with who did you speak with?_________________________________
Briefly explain the issue in which you are requesting
my
assistance:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Please
attach the most recent correspondence you have received from the
federal agency
and any other pertinent information regarding this case.
Mail information
to my Detroit Lakes district office.
714 Lake Avenue, Suite 107
Detroit Lakes, MN 56501