Help with a Federal Agency Form

Privacy Consent Act Form

Please fill out all fields and a print form will be generated. Write in your social security number (required), sign the form (required) and fax it to the district office nearest you.

In accordance with the Privacy Act of 1974, I give Congressman Randy Hultgren authority to act 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:* IL Zip:*

Home Phone:*

Cell Phone:

Work Phone:

E-mail Address:*

Date of Birth:*

A#(if applicable):

C#(if applicable):

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

Print This Form

Use the Generate Request button to produce the document to authorize my office to help you. Then sign it and mail it to the address shown on the document. Please include any other documents or material that you think would help my office help you.