Privacy Release Form

                                                        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:____________________

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