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CONGRESSMAN SANDER LEVIN
Representing the 12th District of Michgan
Privacy Act Release Form
In order to open a case on your behalf, you must complete this form and return it to my Roseville office. You should also include copies of any relevant documents, but please send only copies of your documents. Please fill all blanks which apply. You may fill this form online and then print it to sign, or you may print the blank form and complete it at your convenience. Full Name: ______________________________________ Date of Birth: _____________ Address: __________________________________________________ Apt #: _______ City: ________________________________ State: Daytime Phone: _________________ Other Phone: _________________ E-Mail Addresss: _____________________________________________________ Agency with which you are having a problem: _________________________________________ Social Security Number: ____________________ Alien Registration Number: A _________________________ Veteran's Claim Number: _________________________ Military I.D. Number: __________________________ Branch of Service: _________________ Dates of Service: _______________________ Other Case or Claim Numbers: ______________________________________________ Briefly explain your problem or the information you are requesting: Zip+4: ______________

The Privacy Act of 1974 prohibits the disclosure of personal information without that individual's consent. I agree to allow Congressman Sander Levin or any member of his staff access to any records relating to the problem described above. Signature: _________________________________________ Date: ________________ For assistance in completing this form please phone (586) 498-7122 This form may be returned by fax to: (586) 498-7123 or mail it to: Congressman Sander Levin, 27085 Gratiot Ave., Suite C Roseville, MI 48066