CASEWORK AUTHORIZATION TO REVIEW PERSONAL (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 Signature: _________________________________________________________ Name (printed): _________________________________________________________ Address: _________________________________________________________ _________________________________________________________ Phone (Home): _________________________________________________________ Phone (Work): _________________________________________________________ Social Security Number or _________________________________________________________ Please add the following information Type of Tax (income, employment, etc.): _________________________________________________________ Tax Year(s) or Tax Period(s): _________________________________________________________ Briefly explain the problem. Attach copies of any relevant documentation. _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ PLEASE RETURN THE COMPLETED FORM, and copies of any accompanying documentation to: Congresswoman Debbie Wasserman Schultz |