Response

Privacy Act Consent Form

In accordance with the provisions of The Privacy Act of 1974 (5 U.S.C. § 552a ), your written consent is required so that we may contact a federal agency on your behalf. Since e-mails do not contain a valid signature, they do not fulfill the requirements of the law.
-All information must be written in English (Toda la información debe estar en Inglés) (Tout enfòmasyon yo dwe ekri nan lang angle)

What can we help you with?

CONTACT & IDENTIFICATION INFORMATION

All information must be written in English (Toda la información debe estar en Inglés) (Tout enfòmasyon yo dwe ekri nan lang angle)

Prefix

First Name

Last Name

Address

City

State

Zip

Daytime Phone Number

Cell Phone

Date of Birth

Social Security Number

THIRD PARTY AUTHORIZATION (OPTIONAL)

If you want information regarding your case released to a third party (spouse, family, attorney, etc.) please provide the following information:

All information must be written in English (Toda la información debe estar en Inglés) (Tout enfòmasyon yo dwe ekri nan lang angle)

Name(s) and relationship:

E-mail:

Third Party Contact Information

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Daytime Phone

Cell Phone

ADDITIONAL INFORMATION

All information must be written in English (Toda la información debe estar en Inglés) (Tout enfòmasyon yo dwe ekri nan lang angle)

Name of Federal Agency involved with issue:

If you have contacted another congressional office to assist you, please list the office:

Claim or File Number:

Medicare Number (MBI):

All information must be written in English (Toda la información debe estar en Inglés) (Tout enfòmasyon yo dwe ekri nan lang angle)

Briefly state your problem and the outcome you are seeking below. (Space is limited to 1,500 characters)

Please attached the supporting documents, up to three files and no larger than 15MB a piece.

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DATE AND SIGNATURE

I hereby authorize the office of Senator Marco Rubio to make the appropriate inquiry on my behalf pertaining to my request for assistance. In addition, I authorize the agency to discuss with the office of Senator Marco Rubio any condition, action, and other information associated with ANY past and present application, claim, appeal, and/or case that I have with the agency. I hereby authorize the office of Senator Marco Rubio to make the appropriate inquiry on my behalf pertaining to my request for assistance. In addition, I authorize the agency to discuss with the office of Senator Marco Rubio any condition, action, and other information associated with ANY past and present application, claim, appeal, and/or case that I have with the agency.

Today's Date:

This signature must be from an individual who is 18 years of age or older and is requesting assistance or has a pending case with a federal agency. Third party signatures, including those of immediate family members, are not acceptable. Federal agencies will not release information without the signed consent of the proper individual.

Signature must be in your handwriting.

Sign using your mouse or finger...