Attn:________________________ People ID#:_______________
(for office use only)

Senator Dianne Feinstein

Privacy Release Form

Complete, sign, and return to:

SENATOR DIANNE FEINSTEIN
One Post Street, Suite 2450
San Francisco, CA 94104

Date:

Name:_________________________________________________

Address:_______________________________________________ Zip:_______

Home Phone:___________________________________________

Work Phone:___________________________________________

Federal Agency Involved:_________________________________

Social Security # or Agency File #:__________________________

Have you contacted our office before?_______________________

Have you contacted another congressional office regarding this matter?__________

If “yes” to the above, which office & when?__________________________________

Is this matter currently pending before a local, state, or federal court?___________

Problem:

Please briefly explain your problem and outline the steps that
have been taken by you and the agency with regards to your
situation. In addition, please make your request for assistance as specific as possible. Should you require more
room, feel free to attach a letter addressed directly to the Senator.

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I hereby authorize U.S. Senator Dianne Feinstein and her staff to
make inquiries and obtain information related to my case currently pending with the above
mentioned federal agency.

SIGNATURE:_____________________________________________