Sen. Russ Feingold

Privacy Act Release Form

The Privacy Act of 1974 (Public Law 93-579) prevents agencies from releasing information about you to anyone without your written permission. Therefore, Senator Feingold will need your written signature on this waiver before he can intervene with a federal agency on your behalf. If you have a printer, print this form out, complete it, sign it, and mail it to Senator Feingold's nearest state office. If you do not have a printer, you may request a Privacy Act Release Form from any of Senator Feingold's offices.

I hereby authorize the appropriate federal government agency to release any and all information pertaining to me and my case to Senator Feingold or any member of his staff.



Signature ________________________________________ Date___________

(Please Print)

Name:

Address:

City, State, and Zip Code:

Telephone:

Social Security Number:

Brief Description of Problem: