Fillable Privacy Release Form printable pdf download

Privacy Release Form

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PRIVACY RELEASE FORM

Office of Representative Tim Walz

First District, Minnesota

The Privacy Act of 1974 requires written consent from the constituent before information

can be obtained from a government agency’s records. By law, we cannot intervene on the

constituent’s behalf without his or her express authorization in writing.

NOTE: Members of Congress are empowered to help constituents interact with federal agencies and, in some instances, other

entities. Although Members and their staff cannot force an agency to expedite your case or act in your favor, they can

frequently intervene to facilitate the processes involved, encourage an agency to give your case consideration and, in some

instances, advocate for a favorable outcome.

Full Name

___________________________________________________

Address__________________________________________________________________________________________________

City, State, Zip __________________________________________________________________________________________

Social Security Number ______________________________________ Date of Birth ______________________

Phone (List primary number) _______________________________________________________________________

Email ____________________________________________________________________________________________________

I prefer to be contacted by:  Mail

 Phone

 Email

Please mark the box for the federal issue that requires our attention:

 Veterans Affairs

 Immigration

 Social Security

 IRS

 Medicare

 Other, please list: _____________________________________

Have you contacted other elected officials regarding this issue? If so, please list here:

Have you designated others to speak with us? If so, please list name(s) and number(s) here:

I authorize Congressman Tim Walz and his staff to grant and obtain personal records, files and information about me

pertaining to my request for assistance. I understand that I may revoke this authorization at any time.

Signature ________________________________________________________________ Date _____________________

Signature of primary constituent receiving assistance - Third party signatures are not accepted

Please complete this form in its entirety before returning it to the appropriate office:

Rochester: 1130 ½ 7

St. NW Suite 208, Rochester, MN 55901 or Fax: (507) 206-0650

Mankato: 227 E. Main St. Suite 220, Mankato, MN 56001 or Fax: (507) 388-6181

Privacy Release Form

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