PRIVACY ACT RELEASE

Date:_____________

Name of Agency:  Internal Revenue Service

To Whom It May Concern:

I have sought assistance from United States Senator Sam Brownback on a matter that may require the release of information maintained by your agency, and which you may be prohibited from disseminating under the Privacy Act of 1974.

I hereby authorize you to release all relevant portions of my records or to discuss the issues involved in my case/claim with Senator Brownback or any authorized member of his staff until this matter has been resolved.

               Tax Year(s)                                                                                        Tax Type(s) - [Individual Tax (1040),Employment
                                                                                                                            Taxes (941), Business Income Tax (1120,1065),
                                                                                                                            Describe all others]

               ________                                                                                          _____________________________________
               ________                                                                                          _____________________________________
               ________                                                                                          _____________________________________
               ________                                                                                          _____________________________________
               ________                                                                                          _____________________________________



_______________________________                              ________________________________
Signature of Constituent                                                        Date of Birth

_______________________________                               ________________________________
Street Address                                                                      City, State, Zip 

________________________________                            ________________________________
Home Telephone Number                                                     Work Telephone Number

________________________________                            ________________________________
Social Security Number                                                        Claim/Case Number if applicable
(Individual Tax Matters)                                                                               (Business-related Tax Matters Only)