PRIVACY ACT RELEASE
Date:_____________
Name of Agency: _____________________
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.
_______________________________ ________________________________
Signature
of
Claimant Date of Birth
_______________________________
________________________________
Street
Address Social Security Number
________________________________ ________________________________
City, State,
Zip
Claim/Case Number if applicable
________________________________
Telephone Number
Have you talked to an attorney about your case? ___yes ___no
If yes, please
sign below to authorize Senator Brownback. s office to contact your
attorney about your case.
________________________________
Signature of
Claimant