Constituent Assistance Form
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1Constituent Assistance Form
Privacy Act of 1974(Public Law 93-579)
The Federal Privacy Act prohibits the disclosure of confidential information concerning your affairs
without your written authorization. If you wish for Congressman David Price’s office to make an inquiry
on your behalf, complete the authorization form and return it to the nearest office listed below:
Raleigh District Office
Chapel Hill District Office
U.S. Representative David Price
U.S. Representative David Price
436 N. Harrington Street, Suite 100
1777 Fordham Boulevard, Suite 204
Raleigh, NC 27603
Chapel Hill, NC 27514
Phone: (919)859-5999
Phone: (919)967-7924
Fax: (919)859-5998
Fax: (919)967-8324
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Authorization for Release of Confidential Information
I, ______________________________________, hereby authorize Congressman David Price
(Name)
to obtain confidential information from ____________________________________________
(Government Agency/Office)
or any other federal agency concerning myself/ourselves involving the matter outlined below.
Signature_________________________________________Date_____________________
(Physical Signature Required)
Briefly describe your concerns. Please attach any additional information if needed.
Name: (Mr./Ms.)_______________________________________________________________
Home Address:________________________________________City:____________________
State:_____Zip:__________Phone:(H)_____________________(W)_____________________
Email Address:________________________________________________________________
Social Security Number:_________________________Date of Birth:____________________
Alien Registration Number (if applicable)_____________Military ID (if applicable)______________
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Parent category: Legal