Keyword:
Entire Site
This Section
Subscribe to Rep. Fattah's monthly update
Privacy Consent Act Form
Please fill out all fields and a print form will be generated. Write in your social security number (required), sign the form (required) and fax it to 215.871.4456 or 215.871.4457.
I am aware that the Privacy Act of 1974 prohibits the release of information in my file without my approval. I hereby authorize Congressman Chaka Fattah or his representative to inquire with the following agency on my behalf:
* indicates required field.
Name of Agency:
Prefix: Mr. Ms. Mrs. Dr. Rev. Capt. Rabbi
First Name:*
Last Name:*
Suffix: Jr. Sr. M.D. Ph.D I II III
Street Address:*
Address 2:
City:*
State:* PA Zip:*
Home Phone:*
Cell Phone:
Work Phone:
E-mail Address:
Date of Birth:*
Alien#(if applicable):
Country#(if applicable):
Briefly explain the issue in which you are requesting assistance:*
Please note: By federal law (18 USC, Sec. 205), neither Congressman Fattah nor his staff can involve themselves in private legal matters or represent constituents in judicial proceedings.