Thank you for contacting me to help you deal with a federal agency. My staff offers assistance with matters involving government agencies and programs, and we are happy to have the opportunity to assist you.

The first step in this process is submitting a waiver form to my office with information about your case, signaling that we have your permission to move forward. The Privacy Act of 1974 (5 U.S.C. § 552a) requires that Members of Congress or their staff have written authorization before they can obtain information about an individual's case, so we must have your signature before we can proceed.

You can generate a printable page from the form below, which you should sign and mail to my office at 240 S. Montezuma St #101, Prescott, AZ 86303 or at 211 North Florence Street Suite #3, Casa Grande, AZ 85222.

Please include all pertinent information and claim numbers in your correspondence—such as:

• Your Social Security number for a case involving Social Security;
• VA claim number for a case with Department of Veterans Affairs;
• Medicare number or claim number for Medicare issues;
• Taxpayer identification number (Social Security number, if individual) for an Internal Revenue Service problem, etc.;
• Your address, home phone number and daytime phone number (if different than home) so that we can obtain any additional information from you that might be necessary;
• Copies of any related documents or correspondence that you may have from the agency involved.

PRIVACY ACT RELEASE FORM

I am aware that the Privacy Act of 1974 prohibits the release of information in my file without my approval. Pursuant to 5 U.S.C. 552a, I hereby authorize all appropriate Federal agencies or departments to provide information on my claim/case to Congresswoman Ann Kirkpatrick.