Privacy Act Release Form

To whom it may concern:

I have sought the assistance of Congressman Mike McIntyre 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 have hereby authorized you to release all relevant portions of my records or to discuss problems involved in this case with Congressman McIntyre or any authorized memeber of his staff until this matter is resolved.

I also hereby authorize the Departement of Veterans Affairs to release any information pertaining to past, present, and future VA claims and issues. Also any claims that deal with issues related to Title 38 > Part V > Chapter 73 > Subchapter III > 7332 and Title 38 > Part IV > Chapter 57 > Subchapter I > 5701.


, , ,

 

Print This Form

Use the Generate Request button to produce the document to authorize my office to help you. Then sign it and mail it to the address shown on the document. Please include any other documents or material that you think would help my office help you.

Please mail in the original form.