CASEWORK AUTHORIZATION TO REVIEW PERSONAL
INFORMATION PROTECTED BY THE PRIVACY ACT

(The Privacy Act requires that you authorize access to your private records.  Without your authorization, an inquiry on your behalf will not be possible.)

Date: ___________________

I have asked U.S. Representative Debbie Wasserman Schultz to communicate with
(list Federal agency) __________________________________________ on my behalf. 
In order to respond to her inquiry about me and to giver her status reports on my case, I realize that it may be necessary to release information about that, under the Privacy Act of 1974 (Public Law 93-579) cannot be released without my written consent.  This form is to serve as my consent for the release of such information to Congresswoman Wasserman Schultz or her designee.

Signature:                                 _________________________________________________________

Name (printed):                        _________________________________________________________

Address:                                  _________________________________________________________

                                                _________________________________________________________

Phone (Home):                         _________________________________________________________

Phone (Work):                         _________________________________________________________

Social Security Number or        _________________________________________________________
Alien Number (if INS case)

Please add the following information
ONLY for Internal Revenue Service cases:

Type of Tax (income, employment, etc.): _________________________________________________________

Tax Year(s) or Tax Period(s):                 _________________________________________________________

Briefly explain the problem.  Attach copies of any relevant documentation.

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PLEASE RETURN THE COMPLETED FORM, and copies of any accompanying documentation to:

Congresswoman Debbie Wasserman Schultz
Pembroke Pines City Hall
10100 Pines Blvd., 2nd Floor
Pembroke Pines, FL 33026
Phone: (954) 437-3936 Fax: (954) 437-4776