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Privacy Release Form/request For Congressional Inquiry - Congress Of The United States

WASHINGTON OFFICE:

DORIS O. MATSUI

2311 RAYBURN HOUSE OFFICE BUILDING

DISTRICT, CALIFORNIA

Congress of the United States

WASHINGTON, DC 20515-0506

COMMITTEE ON

(202) 225-7163

ENERGY AND COMMERCE

House of Representatives

DISTRICT OFFICE:

ROBERT T. MATSUI U.S. COURTHOUSE

Washington, DC 20515-0506

501 I STREET, SUITE 12-600

SACRAMENTO, CA 95814

(916) 498-5600

(916) 444-6117 (fax)

PRIVACY RELEASE FORM/REQUEST FOR CONGRESSIONAL INQUIRY

Date: _______________________________

Name: ____________________________________ E-mail:____________________________________

Address: _____________________________________________________________________________

City: ____________________________________ State: _________ Zip: ________________________

Home Phone: ______________________________Work/Cell Phone: ____________________________

ID# (SSN, VA, Alien Registration, etc.) ____________________________________________________

Federal Agency Involved: _______________________________________________________________

Have you ever contacted our office before? _________________________________________________

Have you contacted another congressional office regarding this matter? __________________________

If “yes” to the above, which office & when? ________________________________________________

Is this matter currently pending before a local, state, or federal court? ____________________________

Please briefly explain your problem and outline the steps that have been taken by you and the agency with

regards to your situation. If you need additional room, feel free to attach a letter or write on the back of this form.

I hereby authorize Congresswoman Matsui or her representative to have access to any information and records pertaining to this matter.

Please inform her District Office directly of the results of this inquiry as soon as possible.

Signature: ________________________________________

Privacy Release Form/request For Congressional Inquiry - Congress Of The United States