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Get Privacy Release Form - Barbara Boxer

United States Senator Barbara Boxer PRIVACY ACT CONSENT FORM The provisions of Public Law 93-579 Privacy Act of 1974 prohibit the disclosure of information of a personal nature from the files of an individual without their consent. Accordingly I authorize the staff of Senator Barbara Boxer to access any and all of my records that relate to the problem stated below. Signature Date To begin processing your case please complete all of the following information Circle One Mr. Mrs. Miss Ms. First Name Last Name Date of Birth Social Security Number Address City ZIP Email Phone Number Federal agency with which you need help Briefly explain the problem or the information desired attach additional pages if necessary Please include copies of any relevant documentation related to your request as attachments to this form* Also include the following information if appropriate. IMMIGRATION OTHER MILITARY Alien Registration Priority Date Form Date filed USCIS Receipt Embassy Case EEO Charge Student Lender Name OPM CSA Branch of Service Rank VA File Number VA Office or Medical Center Please list any other Congressional offices that you have contacted about this issue Print and mail your completed form to Senator Barbara Boxer s Oakland office at Attention Casework Department 70 Washington Street Suite 203 Oakland California 94607 Fax 202. 228. 6866 Despite containing a Washington D*C* area code faxes sent to the above fax line will be received in Oakland. Accordingly I authorize the staff of Senator Barbara Boxer to access any and all of my records that relate to the problem stated below. Signature Date To begin processing your case please complete all of the following information Circle One Mr. Signature Date To begin processing your case please complete all of the following information Circle One Mr. Mrs. Miss Ms. First Name Last Name Date of Birth Social Security Number Address City ZIP Email Phone Number Federal agency with which you need help Briefly explain the problem or the information desired attach additional pages if necessary Please include copies of any relevant documentation related to your request as attachments to this form* Also include the following information if appropriate. Mrs. Miss Ms. First Name Last Name Date of Birth Social Security Number Address City ZIP Email Phone Number Federal agency with which you need help Briefly explain the problem or the information desired attach additional pages if necessary Please include copies of any relevant documentation related to your request as attachments to this form* Also include the following information if appropriate. IMMIGRATION OTHER MILITARY Alien Registration Priority Date Form Date filed USCIS Receipt Embassy Case EEO Charge Student Lender Name OPM CSA Branch of Service Rank VA File Number VA Office or Medical Center Please list any other Congressional offices that you have contacted about this issue Print and mail your completed form to Senator Barbara Boxer s Oakland office at Attention Casework Department 70 Washington Street Suite 203 Oakland California 94607 Fax 202. .

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