Privacy Release Form
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1Privacy Release Form
The Privacy Act of 1974 prohibits the government from revealing any information from
personal files of individuals without the express written permission of the person involved.
Disclosure of personal records to a Senator who is acting on behalf of a constituent is
prohibited, unless the individual to whom the record pertains has consented.
I, the undersigned, hereby authorize the release of all pertinent information
to Senator Johnny Isakson to make an inquiry on my behalf to the following
Federal agency:_____________________________________________
(Name of Federal Agency)
Name:
Address:
City, State, ZIP Code:
Social Security # :
Other ID#:
Telephone #:
Signature:
Date:
P
G
A B
D
Y
P
B
:
LEASE
IVE
RIEF
ESCRIPTION OF
OUR
ROBLEM
ELOW
Please return completed form to:
One Overton Park
3625 Cumberland Boulevard, Suite 970
Atlanta, Georgia 30339
Or fax to: 770-661-0768
Or email to : casework@isakson.senate.gov
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Parent category: Legal