Privacy Act Release Form printable pdf download

Privacy Act Release Form

Representative Steven Palazzo – Fourth Congressional District, Mississippi

Under the Privacy Act of 1974, federal agencies are prohibited from disclosing information from your files to anyone without your written

authorization. By completing this form and signing the Privacy Act statement below, you are authorizing the federal agency involved to disclose

such information to U. S. Congressman Steven M. Palazzo and/or members of his staff. Such information will be kept confidential by them. You

also affirm that this request for assistance is in no way an attempt to evade or violate any federal, state, or local law.

PLEASE COMPLETE AND RETURN FORM TO THE DISTRICT OFFICE ASSIGNED TO HANDLE YOUR CASE.

NAME (LAST) ____________________________________ (First) _____________________________________(MI) __________

ADDRESS _______________________________________________ CITY __________________________ ZIP _______________

COUNTY ______________________________ EMAIL _____________________________________________________________

PHONE ________________________________ CELL ____________________________ ALT _____________________________

DATE OF BIRTH _______________________ SSN _______________________________________________________________

THIRD PARTY

__________________________________________________ Relationship? ______________________

(if applicable)

If your matter concerns the US Military or Veterans Affairs, please provide the following information:

BRANCH ______________________________ DATES OF SERVICE _____________ TO __________ RANK _______________

HOME OF RECORD _______________________________ LAST DUTY STATION _____________________________________

DID YOU HAVE COMBAT SERVICE? NO ______ YES _______ CONFLICT ________________________________________

V.A. FILE NUMBER

(if different from SSN) ___________________________________________________________________________________________

Is this matter currently under consideration by an attorney? NO ______ YES _____

Have you contacted any other Congressional office about this matter? NO ______ YES ____ NAME __________________________

NOTE: If you would like Rep. Palazzo to take over your case from another congressional office, you must provide written documentation from that

office indicating that the matter is closed with any other U.S. Representative or Senator’s office before we can proceed on your behalf.

PLEASE EXPLAIN THE ISSUE YOU ARE FACING AND THE OUTCOME YOU WOULD LIKE TO SEE:

(Use reverse side or add another page if necessary, and attach any relevant documentation that may be helpful in resolving your issue.)

______________________________________________________________________________________________________________________

Pursuant to the provisions of 5 U.S. Code 552a (Privacy Act of 1974) P. L. 93-579, I hereby authorize the release of information from

my medical records, any files pertaining to me, or copies thereof, to U. S. Representative Steven M. Palazzo and/or his staff.

SIGNATURE __________________________________________________________________ DATE_______________________

Privacy Act Release Form