Authorization Form printable pdf download

Authorization Form

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Authorization Sheet

Date________________________________________

Name_______________________________________________________________________________

Address_____________________________________________________________________________

City, State, Zip_______________________________________________________________________

Home Phone ________________________

Work Phone___________________________________

Social Security #___________________________ Date of Birth ______________________________

Agency Involved______________________________________________________________________

Numbers Identifying Case (VA claim, Alien number, tax ID, etc.) ______________________________

Date and Place Claim was Filed_________________________________________________________

Please describe problem in detail _________________________________________________________

____________________________________________________________________________________

In accordance with the provisions of the Privacy Act, I hereby authorize Congressman or a member of

his staff to make the appropriate inquiry on my behalf.

Sincerely,

_______________________________________________

(Signature)

Authorization Form