In compliance with the Privacy Act of 1974, I hereby authorize all agencies, departments, and private sector contacts to release all personal information pertaining to my case to Senator Mary L. Landrieu. I have asked for her assistance and give her my permission to pursue any inquiries she deems necessary.

Signature_________________________________ Date:___/___/___

(Please Print Below)

Name:________________________________________________________________________

Address: _____________________________________________________________________

City/Zip: _____________________________________________________________________

Phone Number: (___)__________________ Fax Number: (_____)________________

Other Number:(____)__________________

Date of Birth: ______/_____/_____ Social Security Number:_____________________

Other claim, case, or receipt number, if applicable:_________________________________

Brief Description of Problem:

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