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Privacy Release Form

The Privacy Act of 1974 is a Federal law designed to protect you from unauthorized use and exchange of personal information by Federal agencies. Any information that a Federal Agency has on file regarding your dealings with the United States government may not, with a few exceptions, be given to another agency or to a Senator or Member of Congress without your written permission.

PLEASE DESCRIBE THE SITUATION WITH WHICH YOU ARE REQUESTING
ASSISTANCE:

I hereby request the assistance of the Office of United States Senator Patty Murray in resolving the matter described above and authorize Senator Murray and her staff to receive any information which they might need in order to provide this assistance.

Date:

Signature:
(Print form then sign your name here.)

Name:

Address:

Day Phone:

Evening Phone:

SSN:

Alien Identification:

Other Claim #s ( please specify agencies ):

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