U.S. Congressman Lamar Smith

U.S. Congressman Lamar Smith 21st District of Texas

I hereby authorize CONGRESSMAN LAMAR SMITH to request on my behalf, pertinent to the Freedom of Information and Privacy Act of 1974, access to information concerning me in the files of the Department of __Internal Revenue Service___.

In addition, CONGRESSMAN SMITH is also authorized to see any materials that may be disclosed pertinent to that request.

FULL NAME: ______

HOME ADDRESS STREET: ______

CITY/STATE/ZIP: ______

MAILING ADDRESS (IF DIFFERENT FROM ABOVE): STREET: ______

CITY/STATE/ZIP: ______

HOME PHONE: ______WORK:______

MOBILE: ______

SOCIAL SECURITY NUMBER: ______

REGARDING TAX YEAR(S)______TAX FORMS:______

CLAIM NUMBER: ______DATE OF BIRTH:______

E-MAIL ADDRESS: ______SIGNATURE: ______DATE: ______

INSTRUCTIONS: Please write a brief letter outlining the nature of your problems. Be as specific as possible. Also, please attach any relevant correspondence that you have initiated or received concerning your problem.