Response

The Privacy Act of 1974, P.L. 93-579, became fully effective on September 27, 1975. The purpose of the Privacy Act is to control the federal government's collection and dissemination of personal information about individual citizens. The Privacy Act authorizes the disclosure of records to congressional offices acting on behalf of constituents only when the individual has consented.

Prefix

First Name

Last Name

Address Line 1

City

Zip

Phone

Date of Birth

Have you contacted our office before?

If yes, what date did you contact us?

Do you prefer a Spanish speaker to follow up with you?

Opt-in for office updates?

Social Security Number:

Medicare Number:

Veterans Affairs Claim Number:

Branch of Service:

Dates of Service Started in Month and Year:

Dates of Service Ended in Month and Year:

Immigration 'A' Number

IRS Case #

Tax Year

Did you file a joint tax return?

If Yes, please provide the full names of the other person on the joint tax return.

They will need to submit a separate Privacy Act Waiver form for the IRS to respond to our inquiry.

Other Relevant Case Number:

Have you contacted another congressional office?

How did you hear about our constituent services?

Briefly describe the concern(s) or problem(s) you are having with a federal agency:

Describe the specific resolution you are hoping for:

I authorize U.S. Senator Mark Kelly and/or his staff to publicly share information about my case so that other constituents in the state of Arizona understand the ways the office can assist with government services and benefits. Such public mentions may be included in newsletters, press releases, social media, and other forms of communication. (By providing your initials authorization below, in no way affects the assistance US Senator Mark Kelly and his staff will provide you.)

I authorize Senator Mark Kelly and/or his representatives to request any relevant information in order to assist in responding to my inquiry, in accordance with the provisions of the law. l declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct. I authorize Senator Mark Kelly and/or his representatives to request any relevant information in order to assist in responding to my inquiry, in accordance with the provisions of the law. l declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.

Written name for signature below:

Today's Date

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