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Complete both sides of this form and return it to me. In order to be in compliance with the Privacy Act of 1974, this form must be signed. If you are inquiring on behalf of someone, a family member or other individual, that individual must sign this form. Mr. Mrs. Ms. Dr. Full Name Address City ZIP Code Social Security Number Date of Birth Home Phone Work Phone Cell Phone Email Address I prefer to be contacted by: Home Phone Work Phone Cell Phone Email Federal Agencies Involved H.

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