Privacy Release Form Page 3

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Congressman Ted W. Lieu – Privacy Release
Please read and sign the following:
By filling out this Privacy Release form, I hereby authorize my member of Congress and staff to
conduct any inquiries regarding my case and to be provided with any information relating to it.
Date:
Signature:
Thank you for taking the time to complete this form. Please return it as soon as possible to my Los
Angeles office at the following address:
Congressman Ted W. Lieu
5055 Wilshire Blvd., Suite 310
Los Angeles, CA 90036
(323) 651-1040
(323) 655-0502 – fax
3

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