Office of Congresswoman Jahana Hayes
Phone: (860) 223-8412 / Website: / Fax: 1-877-568-9290
Please complete this form and return to:
108 Bank Street, 2
Floor, Waterbury, CT 06702
The Privacy Act of 1974 requires written consent before information can be obtained from a government agency.
Name: ________________________________
Address: _____________________________
City/State/Zip: __________________________
Phone: ________________________________
Email: ________________________________
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Date of Birth: _____/______/________
Social Security Number: ______-_____-_______
Briefly describe your case and what specific action you are seeking:
Please list other elected officials working on this issue:
What is the current status of your case? (If known)
Do you have an attorney working on your case?
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I, (print your name) _______________________________________ certify, under penalty of perjury, that I 1) provided or
authorized all of the information in this privacy release form and any document submitted with it; 2) reviewed and
understand all of the information contained in my privacy release form and submitted with it; and 3) all of this information
is complete, true, and correct. I authorize any relevant government agency to release information contained in my records
as it pertains to my case status, and to the extent permitted by law, to Representative Congresswoman Jahana Hayes
and her staff.
Signature ___________________________________________________ Date __________________
Third-Party Authorization
(Complete only if you are designating the person named below to give or receive information about your situation.)
NAME: ______________________________________________ RELATIONSHIP TO YOU: _________________
EMAIL ADDRESS: _____________________________________ PHONE: _______________________________