Privacy Act Release/casework Request Form
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1PAUL D. RYAN
SPEAKER OF THE HOUSE
1
D
, W
ST
ISTRICT
ISCONSIN
WASHINGTON OFFICE:
Congress of the United States
1233 L
H
O
B
ONGWORTH
OUSE
FFICE
UILDING
W
, DC 20515-4901
ASHINGTON
(202) 225-3031
House of Representatives
F
: (202) 225-3393
AX
Washington, DC 20515-4901
TOLL-FREE: 1-888-909-RYAN (7926)
INTERNET: paulryan.house.gov
Privacy Act Release/Casework Request Form
Name: ___________________________________ E-Mail: _______________________
I prefer to receive correspondence by E-mail (if provided above): YES _____ NO _____
Address: ________________________________________________________________
City: __________________ State: _____ Zip Code: ________ Date of Birth: _________
Phone (Home): _______________ (Cell): ______________ (Work): _______________
Social Security Number: __________________ Veteran’s Number: ________________
Agency Involved: ________________________________________________________
The Problem Is: (attach an additional sheet(s) if necessary)
**Privacy Act Release**
I request and authorize U.S. Representative Paul Ryan to act on my behalf and to receive
information from proper officials regarding the matter described above. Congressman Ryan is
.
authorized by me to receive on my behalf all correspondence and information about my case
Signed: _______________________________________ Date:_____________________
Please return this completed form to:
Congressman Paul Ryan
20 South Main Street. Suite 10
Janesville, WI 53545
Phone: (608) 752-4050
toll-free in Wisconsin: 1-888-909-RYAN (7926)
Fax: (608) 752-4711
*** Please note that the Privacy Act Release requires that you authorize access to your private records. Your
signature above will enable Congressman Ryan to make the necessary inquiries on your behalf.
JANESVILLE
KENOSHA
RACINE
C
S
C
C
S
C
C
S
C
ONSTITUENT
ERVICES
ENTER
ONSTITUENT
ERVICES
ENTER
ONSTITUENT
ERVICES
ENTER
20 S
M
S
, S
10
5031 7th Avenue
216 6
S
OUTH
AIN
TREET
UITE
TH
TREET
J
, WI 53545
K
, WI 53140
R
, WI 53403
ANESVILLE
ENOSHA
ACINE
(608) 752-4050 . F
: (608) 752-4711
(262) 654-1901 . F
: (262) 654-2156
(262) 637-0510 . F
: (262) 637-5689
AX
AX
AX
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