 
|  | Constituent Services |
| Privacy Release Form | When requesting information from Heather Wilson's office it is sometimes necessary to provide a privacy release form to give us access to retrieve your information. Please print this form, fill it out, sign and mail to:
Congresswoman Heather Wilson
20 First Plaza NW Suite 603
Albuquerque, NM 87102
505-346-6781 phone
505-346-6723 fax
Congresswoman Heather Wilson
1st Congressional District, New Mexico
Name __________________________________________________________
Full Postal Address ________________________________________________
Home phone _________________ Business phone _______________________
Please complete blanks where applicable:
Social Security Number ______________________________________________
Veterans Claim Number ______________________________________________
Military Identification Number ___________________________________________
Other numbers identifying your case _____________________________________
Types of benefits I am seeking __________________________________________
Date and Place claim was filed _________________________________________
Federal agency involved _______________________________________________
Additional information/explanation of request:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
In accordance with the provisions of the Privacy Act, I hereby authorize Congresswoman Heather Wilson or a member of her staff to make the appropriate inquiry on my behalf.
___________________________________
(Signature)
|
 |
|
