Name of agency Congressman LaHood is to contact: __________________________________________________

To Whom It May Concern:
I have sought assistance from Congressman Ray LaHood on a matter that may require release of information maintained by your agency, and which may be prohibited from distributing under the PRIVACY ACT OF 1974.

I hereby authorize you to release all relevant portions of my records or to discuss problems involved in this case with Congressman Ray LaHood or any authorized member of his staff.

Your name (please print):_________________________________________________

Your Signature:________________________________

Today's Date:__________________________________

(this form must be signed by involved person or legal guardian)

Complete Address:_______________________________________________________

Social Security #:_______________________           

Other Identifying #:_____________________

Date of Birth:___________________________           

Telephone number(s):___________________

Please describe the problem and explain what you would like the Congressman to do.
Attach a separate piece of paper if additional space is needed.

Peoria Office:  100 N.E. Monroe, Room 100, Peoria, IL  61602  phone:  309-671-7027; fax:  309-671-7309

Springfield Office:  3050 Montvale, Suite D, Springfield, IL  62704  phone:  217-793-0808; fax:  217-793-9724

Jacksonville Office:  209 W. State Street, Jacksonville, IL  62650  phone:  217-245-1431; fax 217-243-6852