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Casework Privacy Form
U.S. REPRESENTATIVE JACKIE SPEIER
Privacy Release Authorization Form
Due to the Privacy Act of 1974 (Public Law 93-579), Federal government agencies are prohibited from releasing information or discussing anything regarding another individual without that individual’s written permission. Your signature on this page authorizes Congresswoman Jackie Speier and her staff to make any inquiry they deem necessary and receive any pertinent records on your behalf.
Mr. Mrs. Ms.
Name ____________________________________________________________
Address_______________________________ City_________________ State______ Zip Code ________
Telephone Number (H) __________________ (W) __________________ (C) ________________________
Have you contacted another Congressional office? If so, whom? ___________________________________
Other individuals you grant us authority to speak to about your case: ________________________________________________________________________________
Please include the following information only if it pertains to your inquiry:
Veterans Claim # _____________________________ Tax Payer ID # _______________________________
Social Security # _____________________________ Medicare # ________________________________
Immigration A# or Receipt # __________________________________ Date of Birth ________________
Country of Birth ______________________ Place/Date of Entry _________________________________
Please state your request for assistance: _________________________________________________________
**Please attach an explanation of your situation, copies of pertinent documents, letters, etc. regarding your case.
In accordance with the provisions of the Privacy Act, I hereby authorize U.S. Representative Jackie Speier and her staff to receive information pertinent to my request for assistance indicated above.
Signature: ________________________________________ Date: __________________________________
Please return this completed form to: U.S. Representative Jackie Speier, 400 S. El Camino Real,
For Office Use Only: ? Casework ? Information Request ? Referral ? Issue ? Forwarded
Date Received: __________________ Assigned to: __________________ Date Assigned: _____________
Referral Contact: ____________________________ Agency/Org Utilized _____________________________