+----------+----------------------------+---------+--------------------+
|          | ![](media/                 |         |                    |
|          | image1.png){width="1.75in" |         |                    |
|          | heig                       |         |                    |
|          | ht="1.6319444444444444in"} |         |                    |
+----------+----------------------------+---------+--------------------+
| **ZACH   |                            |         |                    |
| WAMP**   |                            |         |                    |
|          |                            |         |                    |
| **       |                            |         |                    |
| CONGRESS |                            |         |                    |
| OF THE   |                            |         |                    |
| UNITED   |                            |         |                    |
| STATES** |                            |         |                    |
|          |                            |         |                    |
| **THIRD  |                            |         |                    |
| D        |                            |         |                    |
| ISTRICT, |                            |         |                    |
| TEN      |                            |         |                    |
| NESSEE** |                            |         |                    |
|          |                            |         |                    |
| *        |                            |         |                    |
| *Privacy |                            |         |                    |
| Act      |                            |         |                    |
| Release  |                            |         |                    |
| Form**   |                            |         |                    |
+----------+----------------------------+---------+--------------------+

**Please complete the following release form and send it to my closest
district office:**

  ------------------------------------ ----------------------------------
  **[Chattanooga District              **[Oak Ridge District
  Office]{.underline}**\               Office]{.underline}**\
  900 Georgia Avenue\                  200 Administration Road, Ste 100\
  Suite 126\                           PO Box 2001\
  Chattanooga, TN 37402\               Oak Ridge, TN 37831\
  (423) 756-2342\                      (865) 576-1976\
  (423) 756-6613 fax                   (865) 576-3221 (fax)\
                                       (800) 883-2369 toll free

  ------------------------------------ ----------------------------------

> [www.house.gov/wamp](http://www.house.gov/wamp)

Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ State\_\_\_\_\_\_\_\_\_\_\_
Zip\_\_\_\_\_\_\_\_\_\_ County\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Phone Number(s) Home\_\_\_\_\_\_\_\_\_\_\_\_
Work\_\_\_\_\_\_\_\_\_\_\_\_ Cell\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

E-Mail\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Fax\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Social Security Number \_\_\_\_\_\_-\_\_\_\_\_\_-\_\_\_\_\_\_ Date of
Birth \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Claim/Receipt \#
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Please explain your situation in detail; use the additional page if
necessary. Let me know if you have contacted any other Local, State or
Federal Agency and the results if applicable:

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(Use additional pages if needed)

**I authorize any Federal Agency or Department relative to my case to
provide information regarding my claim/case to Congressman Zach Wamp or
any member of his staff as required by the Privacy Act of 1974.**

**Signature\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date**

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