Privacy Release Form | Congressman Pete King

PRIVACY RELEASE FORM Author: Alexis Tameron;David Baer Created Date: 11/21/2019 2:35:59 PM Privacy Release Form - Hank Johnson and understand all of the information contained in my privacy release and submitted with it; and 3) all of this information is complete, true, and correct. Print Name: _ _____ Date: _ _____ Signature: _____ Please return signed form to: 5240 Snapfinger Park Drive, Suite 140 . Decatur, GA 30035 U.S. Senator Ted Cruz

Please fill out the appropriate privacy release form and fax or mail a signed copy to my office. Because of the Constitution’s separation of powers, I cannot assist in judicial or court matters, such as child custody, divorce, pending litigation, criminal trials, or imprisonment.

language translations are acceptable to facilitate completion of the form in English. U.S. Department of State Place of Birth I hereby authorize the U.S. Consular Office of the United States of America and the U.S. Department of State to release information regarding me to the following individuals : SECTION A


act on my behalf with , and therefore, waive all rights in the release of any and all related information and records. I also understand that this inquiry may not conclude in my best interest. I sign this waiver in good conscience and without mental reservation. Signature: Date: [Office use only] Staff: Case number: Privacy Release Form - Jim Inhofe The form must be signed by the person requesting assistance before it is faxed, emailed or mailed to either the Tulsa or Oklahoma City offices. IMPORTANT PLEASE READ: The Privacy Release Form is provided as a convenient way to fill out the PDF form that then must be printed and mailed to our office. Immigration Casework In-Take Sheet Dec 11, 2017 CONSULAR OFFICES OF THE UNITED STATES OF AMERICA SECTION A The U.S. Government, by providing the Authorization for the Release of Information Under the Privacy Act Form, cannot under any circumstances compel an individual to complete and submit the form. PLEASE CAREFULLY CONSIDER TO WHOM, AND WHAT INFORMATION IS BEING DISCLOSED.