Privacy Request Form

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OFFICE OF REP. ROBERT C. "BOBBY" SCOTT
CONSTITUENT CONSENT AND INFORMATION FORM

First name:
Last name:

Street:

City: , VA ZIP:

Daytime Phone:

Evening Phone:

Fax:

Email:

Agency involved:

Claim #:

Do you have a lawyer?:

If Yes, Lawyer's Name:

Lawyer's Phone Number:

The following personal information will help our staff track your claim.

Date of birth:
Social Security #:
Immigrant Visa #:
Alien card #:
Veteran #:
Service record #:

Description of problem.

Privacy Act Statement

Under the Privacy Act of 1974, we must have formal authorization from you before seeking disclosure of your records. The authorization must be signed by the person whose case is in question.

In accordance with the Privacy Act of 1974 (5 USC 552), I hereby authorize Representative Robert C. Scott and his designated staff to seek disclosure of all records relevant to my case from the federal agency involved.

Signature:

Date: