Hawley Privacy Act Waiver

Submitted to Veterans & Military Coalition of the Ozarks

1440 State Hwy 248 Ste Q-243, Branson, MO 65616Submitted to VMCO to process
Senator Josh Hawley Privacy Act Waiver
Submit to Senator Josh Hawley's Office. 400 E. 9th Street, Suite 9350 Kansas City, MO 64106 Phone: (816) 960-4694 Fax: (816) 472-6812

Thank you for contacting my office for help. My staff and I respect your right to privacy and will not contact any agency about your case without your express written consent. Please fill out the form below and mail it to my constituent service office at the address listed above.
Applicant Information
Full Name*
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip
Phone Number*
Email*
example@example.com
Social Security Number*
Agency Involved
Agency Case Number
Veterans and Military Issues
Branch of Service*
Rank and Unit
Immigration Issues

If also needed
Receipt Number
Alien Number
Country of Origin
Application Type
Social Security Issues

If also needed
Type of Claim Filed
Initial Claim Date Filed

MonthDayYear
Date
Status of Claim
Reconsideration/ALJ Hearing
What concerns are you having with a federal agency, what specific action are you seeking?
Need Military personnel records, medical records, and DD214 for VA Client
Other elected officials you have contacted to assist?
List here
YesNo
I hereby authorize Senator Josh Hawley or his staff, under the “Right to Privacy Act,” to request and copy any information regarding this matter from identified agencies. I hereby release you from any liability that may arise by furnishing the requested information. I certify, under penalty of perjury, that 1) I provided or authorized all of the information in this privacy release and any document submitted with it; 2) I reviewed and understand all of the information contained in my privacy release and submitted with it; and 3) all of this information is complete, true and correct.

Authorized Representative

Veterans & Military Coalition of the Ozarks, 1440 State Hwy 248, Suite Q-243, Branson, MO 65616; 417-676-0196

Signature (esignature or physical handwritten signature) Date
Date

MonthDayYear
Date
Signature

Powered by Jotform SignClear
Should be Empty:

Submitted to Veterans & Military Coalition of the Ozarks

Senator Josh Hawley Privacy Act Waiver

Applicant Information

Veterans and Military Issues

Immigration Issues

Social Security Issues