Privacy Act Consent Form

In order to better serve you, please print this page, provide your signature and mail it to one of my district offices.

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 the Department of Veterans Affairs;
• Taxpayer identification number (Social Security number, if individual) for an Internal Revenue Service problem
• 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.

Please Note: 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. We must have your signature to proceed with this type of request. Thank you for your understanding and we look forward to swiftly resolving your issue.

I am aware that the Privacy Act of 1974 prohibits the release of information in my file without my approval. I hereby authorize Congressman Paul D. Tonko or his representative to inquire with the following agency on my behalf:

* indicates required field.

Name of Agency:*

Prefix: Mr. Ms. Mrs. Dr. Rev. Capt. Rabbi

First Name:*

Last Name:*

Suffix: Jr. Sr. M.D. Ph.D I II III

Street Address:*

Address 2:

City:*

State:* NY Zip:*

Home Phone:*

Cell Phone:

Work Phone:

E-mail Address:*

Date of Birth:*

Case number(s):

Briefly explain the issue in which you are requesting assistance:*

Please note: By federal law (18 USC, Sec. 205), neither Congressman Tonko nor his staff can involve themselves in private legal matters or represent constituents in judicial proceedings.