I have asked Representative Mark Udall to communicate with your agency on my behalf.
In order to respond to his inquiry about me and to give him status reports on my case/claim, I realize that it may be necessary to release information about me which, under the Privacy Act of 1974 (Public Law 93-579), cannot be released without my written consent.
This letter is to serve as my consent for the release to:
Representative Mark Udall
Address
or his designee, information pertaining to my case/claim.
Name
Date
Address
SSN
Signature