Help With a Federal Agency

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 mail or fax it to the district office nearest you.

I am aware that the Privacy Act of 1974 prohibits the release of information in my file without my approval. I hereby authorize U.S. Congressman John Mica 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:* FL

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:*

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