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Privacy Act Release
The Privacy Act of 1974 (Public Law 93-579) prevents agencies from releasing
information about you to anyone without your written permission. Therefore, I will need your written signature on this waiver before I can intervene with a federal agency on your behalf (a version may also be downloaded;
it requires the free Adobe Acrobat reader). If you have a printer, print this form out, complete it, sign it, and mail or fax it to my Charleston office. If you do not have a printer, you may call to request a Privacy Act Release form to be mailed to you.
Charleston Office
300 Virginia Street, Suite 2630
Charleston, WV, 25301
Telephone: (304) 342-5855
Fax: (304) 343-7144 |
