Privacy Release Form For The Defense Finance And Accounting Service Casework printable pdf download

U.S. Representative Mike Rogers

District Alabama

Privacy Release Form for the

Defense Finance and Accounting Service Casework

Please print or type:

Part 1. Information about you or the person experiencing the problem.

Servicemember’s Full Name: (last)_________________________ (first) _________________ (MI) ____

Your Name (if not Servicemember): (last)_____________________(first) ________________ (MI)____

Street Address: ________________________________________________________________________

City: ____________________________________ State: _______________ Zip: ___________________

Home Phone: _____________________________ Work Phone: ________________________________

Social Security #: __________________________ Serial # ____:________________________________

Branch of Service: _________________________ Discharge Date (if known): ____________________

Date of Birth: _____________________________ Date of Death (if applicable): ___________________

Part 2. Type of Problem You Are Experiencing – Check the box that applies

Payment Problem of Servicemember

SBP Problem of Widow/Widower

Payment Problem of Former Spouse

SBP Problem of Former Spouse

Other

Reason for Requesting Assistance: (Use reverse side if necessary. Attach copies of any letters,

documents, etc., that you feel will be helpful in resolving your problem.):

____________________________________________________________________________________

Pursuant to the Privacy Act of 1974, I authorize the DFAS to release personal information to

Congressman Mike Rogers and/or his staff in order for him to assist me with the above matter.

Signature: _____________________________________________

Date: _______/_____/________

If you live in: Calhoun, Cherokee, Clay,

If you live in: Chambers, Lee, Russell,

If you live in: Coosa, Macon,

Cleburne, Randolph, or Talladega County

or Tallapoosa County

or Montgomery County

Mail to:

Congressman Mike Rogers

1129 Noble Street, Room 104

1819 Pepperell Parkway, Ste 203

7550 Halcyon Summit Drive

Anniston, AL 36201

Opelika, AL 36801

Montgomery, AL 36117

Privacy Release Form For The Defense Finance And Accounting Service Casework