U.S. Senator Catherine Cortez Masto 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 United States 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 Dean Heller _______ Congresswoman Dina Titus _______ Congressman Mark Amodei _______ Congresswoman Jacky Rosen _______ Congressman Ruben Kihuen BRIEF DESCRIPTION OF THE PROBLEM: ______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _________________________________________________ PLEASE RETURN THIS FORM TO: Las Vegas Reno 333 Las Vegas Boulevard South Suite 8016 400 South Virginia Street Suite 902 Las Vegas, Nevada 89101 Reno, Nevada 89501 (702) 388-5020 (775) 686-5750 PAGE 2 of 2 .