Due to provisions of the Privacy Act of 1974 (5 USC 552a), I must have your written permission before I can make an inquiry on your behalf and/or receive any information to complete your request.

Date: _____________________

Dear Max,

I authorize you to make inquiries to the appropriate parties on my behalf.

Signature: ___________________

Name (Mr. Mrs. Ms.) ___________________________________________

Address: ____________________________________________________

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City: ______________________ State: ____________ Zip: ____________

Telephone (Home): __________________ (Work): ___________________

                  (Cell): ____________________ (Fax): ____________________

(SSA#)(File#)(Case#) (LIN or A#): ________________________________

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Date of Birth: _________________

Please state your request and a brief explanation below. Attach any documentation which might help resolve your problem. Please print or type.

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(Please attach additional pages if necessary)