Fillable Privacy Release Form printable pdf download

Congressman Hank Johnson

Congressional District of Georgia

Privacy Release Form

Name:_____________________________________________________ M___ F___

Date of Birth:_________________

Address:_______________________________________________________________________________________________

City:______________________________________

State:____________

Zip Code:_____________________

Home Phone:__________________________________

Cell Phone:_______________________________________

Business Phone:_______________________________

Email:___________________________________________

Would you like to subscribe to Congressman Johnson’s e-newsletter?

Yes:____ No:___

Do you currently have an attorney/veteran service representative working with you?

Yes:____ No:___

Name:_____________________________________________________

Phone:_________________________________

Please provide any applicable identifying information:

Social Security Number:________________________

Alien Number:____________________________________

Veterans Claim Number:________________________

Branch:_________________________________________

Case/Claim Number:___________________________

Date Filed:_______________________________________

Other(s):_____________________________________

Lender & Account Number:_____________________________________________________________________________

Agency Involved:______________________________________________________________________________________

When did you last receive correspondence from the agency:__________________________________________________

Briefly describe the nature of the assistance you are requesting. You may attach any additional documentation.

_______________________________________________________________________________

The Privacy Act of 1974 prohibits the government from revealing any information from personal files of individuals without the express written permission of the person

involved. Disclosure of personal records to a Congressman who is acting on behalf of a constituent is prohibited, unless the individual to whom the record pertains has

consented. I, the undersigned, hereby authorize the release of all pertinent information to and by Congressman Johnson or his representatives to make an inquiry on my behalf.

Signature:_____________________________________________

Date:_________________________

Print:_________________________________________________

Please return signed form to:

5700 Hillandale Drive, Suite 120

Lithonia, GA 30058

Phone: 770-987-2291 Fax: 770-808-2056