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FORMAL REQUEST FOR ASSISTANCE
The Privacy Act of 1974 prohibits the government from releasing information from Federal records without your consent. Please complete and return this form if you would like information to be released from your file so that I can try to help you.
Note: If the person needing help is a minor or incompetent to handle his or her own affairs, the responsible agent can sign; however, a letter of explanation must be included when you return this form.
The undersigned requests Congressman Alan B. Mollohan
regarding:
and authorizes release of information to him about this matter.
Name:
Street address:
City, state and zip:
Signature and date:
Social Security number:
Daytime telephone:
Evening telephone:
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