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**Congressman John Shadegg**

2400 E. Arizona Biltmore Circle, Suite 1290

Phoenix, Arizona 85016

Phone: 602-263-5300 ▪ Fax: 602-248-7733

**Privacy Act Consent Form**

To Whom It May Concern:

In accordance with the provisions of Public Law 93-579 (The Privacy Act
of 1974), I hereby give my consent for the information concerning me to
be furnished to Representative John Shadegg. I have discussed my case
with Congressman Shadegg and/or his representative(s) and I request that
any relevant information he may require to assist in responding to my
inquiry, as his constituent, be provided to him in accordance with the
provisions of the law.

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  Name:                                                                                                      

                                                                                                             

  Address:                                                                                                   

                                                                                                             

  City:                                                         State:                         Zip:          

                                                                                                             

  Telephone                                                     (Work):                                      
  (Home):                                                                                                    

                                                                                                             

  Date of Birth:                                                Place of                                     
                                                                Birth:                                       

                                                                                                             

  Government                                                                                                 
  Agency                                                                                                     
  Involved:                                                                                                  

                                                                                                             

  Social Security                                                                                            
  Number:                                                                                                    

                                                                                                             

  **If                                                                                                       
  Applicable:**                                                                                              

  Alien Number:                                                                                              

                                                                                                             

  Civil Service                                                                                              
  Claim Number:                                                                                              

                                                                                                             

  Veterans                                                                                                   
  Affairs Number:                                                                                            

                                                                                                             

  Branch of                                                     Military                                     
  Service:                                                      Rank:                                        

                                                                                                             

                                                                                                             

  Other                                                                                                      
  congressional                                                                                              
  offices you                                                                                                
  have contacted                                                                                             
  regarding this:                                                                                            

                                                                                                             

  **Please state                                                                                             
  problem on a                                                                                               
  separate sheet                                                                                             
  of paper and                                                                                               
  include copies                                                                                             
  of all relevant                                                                                            
  paperwork.**                                                                                               

                                                                                                             

  Signature:                                                                        Date:                    
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