Privacy Act Release Form Sample
Form g 639 06 20 19.
Privacy act release form sample. Page 3 of 5. Rank title first mi last name rank title first mi last name signature date y m d da form 7433 apr 2009. For example when dealing with social security issues the government agency concerned may ask for additional information before any considerations may be given. Privacy act release form.
The proponent agency is the office of the inspector general. Local language translations are acceptable to facilitate completion of the form in english. If you deny any part of this request please cite each specific exemption that you rely on to justify your refusal to release the information and notify me of appeal procedures available under the law. For use of this form see ar 20 1.
I am aware that the privacy act of 1974 prohibits release of personal information without my. Consular office may contact and to whom to release information with regard to your case. It could be that these companies need these private information before they can perform any kind of service. Privacy act information release statement.
Maiden name if applicable middle name given name. For immigration casework you can download the privacy release form here. The privacy act passed by congress in 1974 establishes certain controls over what personal information is collected by the federal government and. Please complete the authorization below specifying whom a u s.
For general casework you can download the privacy release form here. The privacy act release is doubly important for military veterans or immigrants who deal with agencies that need further information regarding their requests for service from any of the agencies. I authorize access or release of. Although i am unable to guarantee a specific outcome my role is to assure you a fair and thorough review of your case and to seek a timely response from the agency.
Please return the completed authorization to a u s. Please sign and return this form to. Description of records requested continued 15 d. Sample parental consent form 10 free documents in word pdf.
For veterans casework you can download the privacy release form here. To whom it may concern. Therefore a consent form must be completed before we proceed with your issue.
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