Privacy Authorization Form

First Name *	Mddle Name	Last Name *

* Address:

* City: State: * Zip:

* Email:

Primary Phone Number:

Secondary Phone Number:

* Date of Birth:

* Social Security Number:

* Federal Agency Involved:

* Do you have an open claim with this agency?:
Yes No

* If yes, at which office?:

* Address:

* City: State: * Zip:

Office Phone Number:

* Date (or approximate date) claim filed:

* Have you contacted any other elected officials about this problem? If yes, who?:

* Case Claim Number(s):

* Please describe the nature of your claim:

* Have you received a response updating you on the status of your claim? If so, please list:

* PLEASE EXPLAIN WHAT YOU WOULD LIKE FOR THIS OFFICE TO DO ON YOUR BEHALF:

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