A format i had ... tell me if this is helpful
Senator [NAME]
Information Release Form
Under the Privacy Act of 1974, your signature is required as authorization for Sen. [NAME] to contact and work with federal agencies on your behalf. Please complete the following
information, sign the form, and mail it to Senator [NAME and ADDRESS]Name: ______________________________________________________________________
Address: ____________________________________________________________________
City and Zip Code: ____________________________________________________________
Daytime phone: ( ) _____________________ Evening phone: ( ) ____________________
Fax number: ( ) ______________________ Email: _________________________________
Social Security number: _______________________________
Veteran Case Identification number, CSA number,
IRS number, INS number, or other relevant ID: _________________________________
Federal agency you need help with: ____________________________________________
Brief description of the problem (you may attach additional pages or copies of related
documents):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
I authorize the Office of United States Senator [NAME] to address the matter
described above on my behalf and to receive any relevant information the Senator
and his staff may need in their efforts to provide assistance to me.
________________________________________________________
Signature and Date
Please print and mail to: Senator [Senator\'s NAME]
[ADDRESS]
