Step 1
Ensure that the person requesting assistance lives in the Fifth District of Minnesota.
Step 2
Fill out this form and press the "Send & Print Privacy Form" at the bottom of the page.
If you have questions about this form, please call 612-522-1212
Step 3
Print out the privacy authorization form on the next page and have the person requesting assistance sign it.
Important: Due to the Privacy Act, a copy of the signed form must be faxed, e-mailed or mailed to our Minneapolis office before we can begin assisting you.
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| Personal Information |
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Ms., Mr., Dr., etc.
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Both your first and last name are required
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We need a ZIP Code to ensure that the person requesting assistance lives in the Fifth District of Minnesota.
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A primary phone number is required.
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An e-mail address is required.
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NOTE: Your Social Security Number is NOT sent to our office; it is required for the privacy release form to print out on the next page.
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| Details for Assistance with a Federal Agency |
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Need help selecting the right federal agency? Please call 612-522-1212 for assistance.
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