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U.S. SENATOR CHRIS COONS of DELAWARE www. coons. senate. gov 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 Chris Coons to make inquiries and to access any and all of my records or files as necessary to assist me in the matter I have stated below Signature Date INFORMATION ABOUT YOU AND YOUR CASE First Name M. I. Last Name Date of Birth Street Address City State Zip Email Address Daytime Phone Number Evening Phone Number Do you currently have a case pending before a local state or federal court pertaining to this matter Circle One YES or NO Federal Agency Involved Your Social Security Number Your Alien Registration Number if applicable U*S* CIS Application Form Number Rank and Military Branch of Service Are you currently working with the offices of Senator Carper or Congressman Carney on this matter Circle One YES or NO If yes please specify In the event of an emergency do you authorize our office to discuss your case with a friend or relative Circle One YES or NO Send this form along with a detailed letter and all supporting documentation to If resident of New Castle County Office of U*S* Senator Chris Coons or Attn Constituent Affairs 1105 N* Market Street Suite 100 500 West Loockerman Street Suite 450 Wilmington DE 19801-1233 Dover DE 19904 fax 302-573-6351 fax 302-736-5609 Rev* 1/13. Accordingly I authorize the staff of Senator Chris Coons to make inquiries and to access any and all of my records or files as necessary to assist me in the matter I have stated below Signature Date INFORMATION ABOUT YOU AND YOUR CASE First Name M. I. Last Name Date of Birth Street Address City State Zip Email Address Daytime Phone Number Evening Phone Number Do you currently have a case pending before a local state or federal court pertaining to this matter Circle One YES or NO Federal Agency Involved Your Social Security Number Your Alien Registration Number if applicable U*S* CIS Application Form Number Rank and Military Branch of Service Are you currently working with the offices of Senator Carper or Congressman Carney on this matter Circle One YES or NO If yes please specify In the event of an emergency do you authorize our office to discuss your case with a friend or relative Circle One YES or NO Send this form along with a detailed letter and all supporting documentation to If resident of New Castle County Office of U*S* Senator Chris Coons or Attn Constituent Affairs 1105 N* Market Street Suite 100 500 West Loockerman Street Suite 450 Wilmington DE 19801-1233 Dover DE 19904 fax 302-573-6351 fax 302-736-5609 Rev* 1/13.

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