Privacy Form

To comply with the Privacy Act of 1974, which provided that as of September 27, 1974, disclosures of information of a personal or confidential nature would not be permitted to third parties without the written consent of the individual involved.  You are required to complete this form before we can make an inquiry on your behalf.

This is to certify that I, __________________________________________ authorize
							(Print your name)

Congressman Cliff Stearns to contact ____________________________________ on my
Behalf.							(Name of Federal Agency)

I also authorize that agency and/or person to release any information or record available, which are pertinent to this inquiry, to Congressman Cliff Stearns or a member of his staff.

Signature_______________________________________________________________________

Address_________________________________________________________________________

City____________________________ State__________________ Zip___________________

Home Phone___________________________ Work Phone_______________________________

Social Security Number_________________________ Date of Birth__________________

Other ID Numbers________________________________________________________________
*** If you are in the military, indicate your home of record address below

** Home of Record Address_______________________________________________________

Description of Problem
If additional explanation is needed, please use another sheet. (Do NOT write on the back of this sheet)

_______________________________________________________________________________


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Please return by mail to: Congressman Cliff Stearns, 115 Southeast 25th Avenue, Ocala, FL  34471