PRIVACY RELEASE FORM
COUNTY:_____________________________ DATE:__________________________________
HAVE YOU CONTACTED CONGRESSMAN ROGERS BEFORE?_______________________
NAME:________________________________________________________________________
ADDRESS:_____________________________________________________________________
CITY/STATE/ZIP:_______________________________________________________________
HOME PHONE:_________________________ OTHER PHONE:_________________________
EMAIL ADDRESS:______________________________________________________________
DATE OF BIRTH:_______________________ SOC. SECURITY #:_______________________
VAC #:____________ MARRIED?_________ SPOUSE’S NAME:________________________
NUMBER OF CHILDREN UNDER AGE 18:___ OTHER ID #’s:__________________________
TOTAL INCOME OF ALL FAMILY MEMBERS:______________________________________
FROM WHAT SOURCES?________________________________________________________
DESCRIPTION OF INQUIRY OR CLAIM
(Be sure to complete this section)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
(You may continue on the back if necessary)
PRIVACY ACT RELEASE
I hereby authorize Congressman Harold Rogers (KY-05) and those acting on his behalf, in order to be of assistance to me, to obtain information about me in accordance with applicable laws and regulations.
(X) SIGN HERE:__________________________________ DATE:____________________
PLEASE MAIL TO:
OFFICE OF U.S. CONGRESSMAN HAL ROGERS
ATTENTION: CASEWORK
551 CLIFTY STREET
SOMERSET, KY 42501
NOTE: IF YOU HAVE ANY QUESTIONS, PLEASE CALL: (800) 632-8588
OFFICE USE ONLY:
STAFF PERSON:_________________________________ CASE:____________________
