Congressman Walter B. Jones

Congressman Walter B. Jones
Constituent Request for Service
Privacy Act Statement

In accordance with the Privacy Act of 1974 (5 USC 552), I hereby authorize Representative Walter B. Jones and his designated staff to seek disclosure of all records relevant to my case from the federal agency involved. (Under the Privacy Act of 1974, we must have formal authorization from you before seeking disclosure of your records. The authorization must be signed by the person whose case is in question.)

Signature:_______________________________________________ Date:________

Description of Problem:__________________________________________________

______________________________________________________________________

Attach additional pages if necessary. Attach photocopies (no originals please) of all relevant documents.

Agency Involved:____________________________

Date of Birth:_______________________________

Social Security #:___________________________

Alien Card #:_______________________________

Immigrant Visa#:___________________________

Veteran #:_________________________________

Service Record #:___________________________

Claim #:___________________________________

Mr./Mrs./Ms./Miss (please circle one)

First Name:__________________________________

Last Name:__________________________________

Address:____________________________________

City:___________________ Zip Code:___________

Telephone (day):____________________________

Telephone (night):___________________________

Fax:____________ Email:______________________

Please return this form to:
Congressman Walter B. Jones
1105-C Corporate Drive
Greenville, NC 27858