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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 ________

County _____________Fax______________________ E-Mail ___________________________________

 

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, Suite 410, San Mateo, CA 94402, or via facsimile at (650) 375-8270.

 

For Office Use Only:     ? Casework    ? Information Request   ? Referral   ? Issue   ? Forwarded

Date Received: __________________   Assigned to: __________________     Date Assigned: _____________

Referral Contact: ____________________________ Agency/Org Utilized _____________________________