Privacy Release Form
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1
2
3Los Angeles Office:
5055 Wilshire Blvd., Suite 310
Los Angeles, CA 90036
(323) 651-1040
(323) 655-0502 - fax
Manhattan Beach Office:
th
1600 Rosecrans Avenue, 4
Floor
Manhattan Beach, CA 90266
(310) 321-7664
CONGRESSMAN TED W. LIEU
P
R
F
RIVACY
ELEASE
ORM
In order for my office to assist you, please:
Fill out all three pages of this form completely
Enclose copies of any documents that are related to your case
If you have questions regarding this form, please contact my Los Angeles office at (323) 651-1040.
Mrs.
Ms.
Miss
Mr.
First Name
Middle Initial
Last Name
Residential Street Address
City, State and Zip Code
Mailing Address – if different from residential
Work Telephone Number
Home Telephone Number
Cell Phone Number
E-mail Address
Date of Birth
Social Security Number
Veteran’s Claim Number (if applicable)
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