Privacy Act Release Form

Privacy Act Release Form

The Privacy Act Release Form must be complete, received from a resident or employer of Congressional District 7 and pertain to a matter with a

federal agency. Cases are not accepted from lawyers.

_______________________

Prefix:

________

First Name:

Last Name:

____________________________________________

__________________________________

____________

_______________

Street Address:

____________

City:

Zip:

________________________________

_________________________________________

Phone:

Email Address:

___________________________

Federal Agency Involved:

Social Security Number:

_________________________________

*U.S. Citizenship and Immigration Services inquiries: Please provide a copy of the receipt of the application for which you are

requesting assistance.

Please explain the problem:

What is the current status of the problem?

How would you like my office to help you?

RETURN THIS FORM via MAIL OR FAX:

U.S. Representative John Culberson

10000 Memorial Drive, Suite 620

Houston, TX 77024-3490

202.225.4381 (fax)

HONESTY POLICY:

Please understand that by requesting assistance from my office, you are obligated to provide true and correct information

regarding your situation. Failure to disclose all information or any deliberate attempt to mislead me or my staff may result in the termination of

.

assistance

______________________________________________

________________________

SIGNATURE:

___

DATE:

Due to the provisions of the Privacy Act of 1974 (Title 5, Section 552A of the United States Code) permission in writing is required before making an inquiry on your behalf. Completing and

signing this form authorizes Rep. John Culberson to make inquiries to the appropriate officials on your behalf