Privacy Release Form
Congressman
Mike Turner
3rd Congressional District,
Name
_______________________________________________________________________________________________
Full Postal Address
____________________________________________________________________________________
Home phone _________________ Business phone
___________________________________________________________
Please complete
blanks where applicable:
Social Security Number
_________________________________________________________________________________
Veterans Claim Number
_________________________________________________________________________________
Military Identification Number
_____________________________________________________________________________
Other numbers identifying your case
_________________________________________________________________________
Types of benefits I am seeking _____________________________________________________________________________
Date and Place claim was filed
_____________________________________________________________________________
Federal agency involved
__________________________________________________________________________________
Additional
information/explanation of request:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
In accordance with the provisions of the
Privacy Act, I hereby authorize Congressman Mike Turner or a member of his
staff to make the appropriate inquiry on my behalf.
________________________________________________________________________
(Signature)