Response

Privacy Act Release Form

Senator Warner’s office stands ready help you work through a problem you may have with a federal agency. Acting as a liaison between you and the federal government, office staff can often help you answer questions, find resources or resolve problems. The office cannot promise you a specific outcome from an agency or referral. Staff will do their best to help you receive a full and fair response.

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.

What can we help you with?

CONTACT & IDENTIFICATION INFORMATION

Prefix

First Name

Middle Name

Last Name

Suffix

Address

City

State

Zip

Primary Phone Number

Secondary Phone Phone

Date of Birth (Please enter MM/DD/YYYY)

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:

Name(s) and relationship:

E-mail:

Third Party Contact Information

Prefix

First Name

Middle Name

Last Name

Suffix

Address Line 1

City

State

Zip

Primary Phone Number

Secondary Phone Number

ADDITIONAL INFORMATION

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 (Ex. - VA File Number, Visa Case Number or other agency identifying number):

For Office of Personnel Management, please provide the CSA/CSF Number:

For Department of Labor concerns, please provide the OWCP Number:

For Department of Education concerns, please provide the Loan Number:

For Internal Revenue Service concerns pertaining to a business, please provide the EIN Number:

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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2nd Attachment

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3rd Attachment

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DATE AND SIGNATURE

I hereby authorize the office of Senator Mark Warner 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 Mark Warner 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 Mark Warner 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 Mark Warner 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...