Office of U.S. Senator Herb Kohl

The Privacy Act of 1974 (Public Law 93-579) prevents agencies from releasing information about you. Therefore, Senator Kohl will need your written signature on this waiver before he can intervene on your behalf. If you have a printer, print this form, complete it, sign it, and mail it to Senator Kohl's nearest state office. If you do not have a printer, you may request a Privacy Act Release Form from any of Senator Kohl's offices.

I hereby authorize the appropriate federal government agency to release any and all information pertaining to me and my case to Senator Herb Kohl or any member of his staff. 

Signature   ____________________________________Date____________

Please Print Carefully: 

Name   ______________________________________________________

Street Address _________________________________________________

City __________________________State______________ ZIP _________

Home Phone _________________       Work Phone _____________________

Cell Phone _________________ E-Mail _____________________________

Social Security Number __________________________________

VA Claim Number (if applicable) ____________________________

Medicare I.D. Number (if applicable) _________________________

Alien Receipt Number (if applicable) _________________________

Alien Registration Number-included in all Immigration applications (if applicable) _______________

Please provide a statement of how you feel Senator Kohl could assist you or submit a separate letter.  Include the name of the federal agency you are seeking assistance with and any important dates, deadlines, and/or contacts related to your situation.  __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________