Privacy Release Form Page 2
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2PRIVACY RELEASE FORM
Office of Representative Tim Walz
First District, Minnesota
The following information is required before we can determine how best to
serve you
What problem(s) are you experiencing with the federal agency involved? Provide a
detailed account, include copies of any additional correspondence or documentation that
you have initiated or received in this matter as well as pertinent document or status
identification information.
To date, what action have you taken on your own to resolve this issue? Have you
contacted the federal agency? If so, please include the response that you received.
What is your desired outcome in this matter?
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
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Mankato: 227 E. Main St. Suite 220, Mankato, MN 56001 or Fax: (507) 388-6181
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