Privacy Act Release Form
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

Name (printed)_______________________________________________

Street Address_______________________________________________

City________________________________________________________

Home Phone _________________Work Phone _____________________

E-Mail______________________________________________________

Social Security Number_______________________________________

Alien Number (A number)____________________________________

Application Receipt Number______________________________

Brief Description of Problem: