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Senator Byrd

Leadership.      Character.      Commitment.

PRIVACY ACT RELEASE FORM

To Whom It May Concern:

I am aware that the Privacy Act of 1974 prohibits the release of information in my file without my approval.  I authorize the _________________________ (agency name) to provide information on my claim/case to Senator Byrd.

Signature ________________________________________

(Please print or type the information needed below.)

Name:                                 _________________                                     

Address:                            _______________                                          

                  _______________                                                                     

                    _______________                                                                  

                      _______________                                                                

Telephone:     _____________                                                                 

Social Security Number and/or claim number:                                             

_____________________________________________                        

Please provide below a brief description of the problem: