SENATOR SCHMITT Privacy Act Release Waiver

SENATOR ERIC SCHMITT Privacy Act Release Waiver
The Privacy Act of 1974 mandates that a citizen must supply written consent before a federal agency can provide information to this office for assistance. By completing and signing this form, you authorize Senator Eric Schmitt and his staff to make inquiries and obtain information regarding this issue on your behalf from the federal agencies listed below
Personal Information
Full Name (First Middle Last)
Date of Birth

MonthDayYear
Social Security Number
Street Address
City/State
Zip code
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
What agency is involved Please use the agencys complete name
Please describe the issue you have been experiencing with this agency noting the steps you have previously taken to resolve this matter If more space is needed please attach a separate page
Have you contacted any other elected officials or private attorneys to assist in resolving this situation If so please list them below
Are you currently working with an attorney to address this matter? If so, please provide his/her name and contact information
I hereby authorize Senator Eric Schmitt or his staff, under the “Right to Privacy Act,” to request and copy any information regarding this matter from identifiedagencies. I hereby release you from any liability that may arise by furnishing the requested information. I certify that 1) I provided or authorized all of theinformation in this privacy release and any document submitted with it; 2) I reviewed and understand all of the information contained in my privacy releaseand submitted with it; and 3) all of this information is complete, true and correct.
Signature

Clear
Date

MonthDayYear
Date
Signature of Authorized Representative (if required)

Clear
Date signed by Authorized Representative

MonthDayYear
Date
After this form is submitted, it will be reviewed by VMCO for accuracy, then forwarded to Senator Eric Schmitt’s office for evaluation.
Should be Empty:

SENATOR ERIC SCHMITT Privacy Act Release Waiver