CASE INFORMATION AND PRIVACY RELEASE FORM

AUTHORIZATION

In order for Senator Boxer to assist you, it is necessary that you provide all the information requested below. Please print out the form, complete it, sign it, and mail it to the address listed below.

Please circle: Mr., Mrs., or Ms.

Name: ______________________________________________________________________

Address: ____________________________________________________________________

City and Zip Code: ____________________________________________________________

Daytime phone: ____________________ Evening phone: ____________________

Fax number: ____________________ Email: ____________________

Social Security number: ____________________

Please provide any other tracking numbers relevant to your case, such as Veteran Case Identification number, CSA number, IRS number, INS number: ____________________

Federal agency you need help with: __________________________

Brief description of the problem (attach more pages if necessary):

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

 

I hereby request the assistance of the Office of United States Senator Barbara Boxer in addressing the matter described above, and authorize Senator Boxer and her staff to receive any information which they may need in order to provide this assistance.

______________________________________________
Signature* and Date

*Note: In order to comply with the provisions of the Privacy Act of 1974 and to be of assistance with claim(s), it is necessary that your signature be on file. (in bright contrasting color)

Please print and mail to:

United States Senator Barbara Boxer
Attention: Casework
1700 Montgomery Street, Suite 240
San Francisco, CA 94111
(please attach copies of any supporting documents)