Privacy Release Form

Privacy Release Form

Note: Fields marked with an * are required.

County *

Date *

Have you contacted the Congressman before? *

Yes No

Name *

Address *

City *

State *

Zip

Home Phone *

Other Phone

Email Address

Date of Birth *

Soc. Security #

VAC #

Married? *

Yes No

Spouse's Name

Number of children under age 18 *

Other ID #'s

Total Income of all family members *

From what sources? *

Description of Inquiry or Claim *

(Be sure to complete this section)

Human Validation

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