Privacy Release Form printable pdf download

Privacy Release Form

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CASE NUMBER

Privacy Release Form

The Privacy Act of 1974 (5 U.S.C. sec. 552a) is a Federal law designed to protect you from unauthorized

use and exchange of personal information by Federal agencies. Any information that a Federal Agency

has on file regarding your dealings with the United States government may not, with a few exceptions,

be given to another agency or a Member of Congress without your written permission.

Due to the Privacy Act, you must complete and sign this form authorizing Congressman José E. Serrano

and members of his staff to obtain the information needed to respond to your request for assistance.

Underlined fields are required.

NAME:

ADDRESS:

APT:

ZIP:

PHONE 1:

Home

PHONE

Home

Work

Mobile

EMAIL:

SS#:

A#:

DATE OF BIRTH:

MILITARY UNIT/ DEPARTMENT (if applicable):

ADDRESS:

CITY:

STATE:

ZIP +4:

Pursuant to the Privacy Act of 1974, I hereby authorize appropriate governmental agencies to release

information about me that is relevant to my inquiry to U.S. Representative José E. Serrano.

SIGNATURE:___________________________________________

DATE:_________________________________

Please return the signed original of this form to:

Congressman José E. Serrano

788 Southern Blvd.

Bronx, New York 10455

Privacy Release Form