Click here to view pdf
PRIVACY RELEASE FORM
I hereby authorize CONGRESSMAN LAMAR SMITH to request on my behalf, pertinent to the Freedom of Information and Privacy Act of 1974, access to information concerning me in the files of the Department of _____________________________________________________________________.
In addition, CONGRESSMAN SMITH is also authorized to see any materials that may be disclosed pertinent to that request.
FULL NAME:______________________________________________________________
HOME ADDRESS
STREET: _________________________________________________________________
CITY/STATE/ZIP: __________________________________________________________
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
STREET: _________________________________________________________________
CITY/STATE/ZIP: __________________________________________________________
HOME PHONE: _________________WORK:_________________
MOBILE: _________________
SOCIAL SECURITY NUMBER: ____________________________
CLAIM NUMBER: _______________________________________
DATE OF BIRTH: ________________________________________
E-MAIL ADDRESS: ______________________________________
SIGNATURE: ___________________________________________
DATE:_______________________
INSTRUCTIONS:
Please write a brief letter outlining the nature of your problems. Be as specific as possible. Also, please attach any relevant correspondence that you have initiated or received concerning your problem.
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________ |