Congressman Joe Knollenberg
30833 Northwestern Highway Suite 100
Phone: (248) 851-1366
Fax: (248) 851-0418
Please call and speak to a member of our casework staff before faxing
this privacy waiver form to our office.
Date________________________________________
Name_______________________________________________________________________________
Email________________________________________
Address_____________________________________________________________________________
City, State, Zip_______________________________________________________________________
Home Phone ________________________ Work Phone___________________________________
Social Security #___________________________ Date of Birth ______________________________
Agency Involved______________________________________________________________________
Numbers Identifying Case (VA claim, Alien number, tax ID, etc.) ______________________________
Date and Place Claim was Filed__________________________________________________________
Please describe problem in detail _________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
In accordance
with the provisions of the Privacy Act, I hereby authorize Congressman
Knollenberg or
a member of his staff to make the appropriate inquiry on my behalf.
Sincerely,
_______________________________________________
(Signature)