U.S. Senator Privacy Act Release Form

The Privacy Act of 1974 is a federal law designed to protect you from any unauthorized use and exchange of personal information by federal agencies. Any information that a federal agency has on file regarding your dealings with the government may not, with a few exceptions, be given to another agency or Member of Congress without your written permission.

To Whom It May Concern:

I hereby request the assistance of the Office of United States Senator Catherine Cortez Masto to resolve the matter described on the next page(s). I authorize Senator Catherine Cortez Masto and her staff to receive any information they may need to provide this assistance. The information I have provided to Senator Catherine Cortez Masto is true and accurate to the best of my knowledge and belief. The assistance I have requested from Senator Cortez Masto’s office is in no way an attempt to evade or violate any federal, state, or local law.

SIGNED:______DATE:_____/_____/_____

CONTACT INFORMATION (PLEASE PRINT):

Full Name:______

Date of Birth:_____/_____/_____ Social Security Number:_____-____-_____

Mailing Address:______Apt/Suite:______

City:______State:______Zip:______

Home Phone:______Work Phone:______

Cell Phone:______Fax Number:______

E-mail Address:______

Case or Claim Number (if applicable):______

Alien Number or WAC (if applicable):______

PAGE 1 of 2 Have you contacted another Congressional office or do you plan on contacting another Congressional office for assistance with this matter? ___YES___NO

If yes, which one(s)? ______U.S. Senator ______Congresswoman ______Congressman ______Congresswoman ______Congressman

BRIEF DESCRIPTION OF THE PROBLEM: ______

PLEASE RETURN THIS FORM TO:

Las Vegas Reno 333 Boulevard South Suite 8016 400 South Virginia Street Suite 902 Las Vegas, 89101 Reno, Nevada 89501 (702) 388-5020 (775) 686-5750

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