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| !       | **United States Senator Michael D. Crapo**                 |
| [](medi |                                                            |
| a/image | **Privacy Release Form**                                   |
| 1.png){ |                                                            |
| width=" |                                                            |
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| 5555in" |                                                            |
| he      |                                                            |
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| 334in"} |                                                            |
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**Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Social Security Number:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Home Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Alternate Phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**E-mail:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Contact Preference: E-mail\_\_\_\_\_ USPS mail\_\_\_\_**

**Address:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
City and Zip:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Case Number:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date of
Birth:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Regarding:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\*Please feel free to attach additional information and
documentation.**

**Due to the Privacy Act of 1974 (PL 93‑579), Federal and State agencies
are prohibited from releasing information or discussing anything
regarding another individual without that person's written permission.
Your signature on this page authorizes me, and/or my representatives, to
contact the proper officials on your behalf, discuss the issue, and
receive any pertinent information. [Your signature also gives me
permission to send a copy of this form and any attached letters or
supporting documentation to the appropriate agency.]{.underline}**

**Signature\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

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| [**    | [**[S    | *         | [     | [**[   | [*      | [**[N  |
| [Idaho | outhwest | *[Eastern | **[Ea | South- | *[North | orth-C |
| State  | ern]{.un | Idaho,    | stern | Centra | Idaho]  | entral |
| ]{.und | derline} | No        | I     | l]{.un | {.under | Reg    |
| erline | **](http | rth]{.und | daho, | derlin | line}** | ion]{. |
| }**](h | ://crapo | erline}** | South | e}**]( | ](http: | underl |
| ttp:// | .senate. |           | ]{.un | http:/ | //crapo | ine}** |
| crapo. | gov/cont | 490       | derli | /crapo | .senate | ](http |
| senate | act/cald | Memorial  | ne}** | .senat | .gov/co | ://cra |
| .gov/c | well_off | Dr. Suite | ](htt | e.gov/ | ntact/c | po.sen |
| ontact | ice.cfm) | 102\      | p://c | contac | da_offi | ate.go |
| /boise |          | Idaho     | rapo. | t/twin | ce.cfm) | v/cont |
| _offic | 524 E.   | Falls,ID  | senat | _falls |         | act/le |
| e.cfm) | C        | 83402     | e.gov | _offic | 610     | wiston |
|        | leveland |           | /cont | e.cfm) | Hubbard | _offic |
| 251 E. | Blvd.    | (208      | act/p |        |         | e.cfm) |
| Front  | Suite    | )522-9779 | ocate | 202    | Suite   |        |
| St.    | 220\     |           | llo_o | Falls  | 209\    | 313    |
| Suite  | Cal      | (208      | ffice | Ave.   | Coeur   | \'D\'  |
| 205\   | dwell,ID | )529-8367 | .cfm) |        | d\'     | St.    |
| Bo     | 83605    | fax       |       | Suite  | A       |        |
| ise,ID |          |           | 275   | 2\     | lene,ID | Suite  |
| 83702  | (208)    |           | S.    | Twin   | 83814   | 105\   |
|        | 455-0360 |           | 5^th^ | Fa     |         | Lewis  |
| (      |          |           | Ave.  | lls,ID | (208)6  | ton,ID |
| 208)33 | (208)    |           |       | 83301  | 64-5490 | 83501  |
| 4-1776 | 455-0358 |           | Suite |        |         |        |
|        | fax      |           | 225\  | (      | (208)6  | (      |
| (      |          |           | Po    | 208)73 | 64-0889 | 208)74 |
| 208)33 |          |           | catel | 4-2515 | fax     | 3-1492 |
| 4-9044 |          |           | lo,ID |        |         |        |
| fax    |          |           | 83201 | (      |         | (      |
|        |          |           |       | 208)73 |         | 208)74 |
|        |          |           | (20   | 3-0414 |         | 3-6484 |
|        |          |           | 8)236 | fax    |         | fax    |
|        |          |           | -6775 |        |         |        |
|        |          |           |       |        |         |        |
|        |          |           | (20   |        |         |        |
|        |          |           | 8)236 |        |         |        |
|        |          |           | -6935 |        |         |        |
|        |          |           | fax   |        |         |        |
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