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PDF: Office of Senator Chris Dodd

Download 0 times Source: dodd.senate.gov // Topic: U.S. Government File Size: 10.62 kb // Total of Page: 1 Page(s) Share this info: Sample of page (click to enlarge) Short Desciption: Office of Senator Chris Dodd. Information Release Form ? Privacy Act of 1974. Under the Privacy Act of 1974, your signature is required as authorization for ... Content Inside: Office of Senator Chris Dodd Information Release Form -- Privacy Act of 1974 Under the Privacy Act of 1974, your signature is required as authorization for Senator Dodd to contact and work with federal agencies on your behalf. Please complete the following information, sign the form, and mail it to Senator Dodds Hartford, CT office. Name: ______________________________________________________________________ Address: ____________________________________________________________________ City and Zip Code: ____________________________________________________________ Daytime phone: ( Fax number: ( ) _____________________ Evening phone: ( ) __________________ ) ______________________ Email: ________________________________ Social Security number: _______________________________ Veteran Case Identification number, CSA number, IRS number, INS number, or other relevant ID: ___________________________________ Federal agency you need help with: _______________________________________________ Brief description of the problem (you may attach additional pages or copies of related documents): ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ I authorize the Office of United States Senator Chris Dodd to address the matter described above on my behalf and to receive any relevant information the Senator