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PRIVACY ACT RELEASE FORM As required by the Privacy Act of 1974 I authorize U.S. Representative Dan Benishek M. D. to obtain information from any federal government records regarding me in connection with my claim or problem* Agency Signature Date / Name First Home Telephone Work Telephone Date of Birth / 2012 Last Social Security Number - - Address City State Zip County Claim Number if applicable Please describe your problem and the current status of your claim* This matter has been brought to the attention of former Congressman Bart Stupak Levin and/or Senator Debbie Stabenow. Please check all that apply. Senator Carl Mail or Fax this form Gaylord 810 S* Otsego Ave. Ste 105 Gaylord MI 49735-1780 Tel 989-448-8811 Fax 989-448-8858 Petoskey 200 Division St* Ste 178 Petoskey MI 49770-2465 Tel 231-348-0657 Fax 231-348-0653 Iron Mountain 500 S* Stephenson Ave. Ste 500 Tel 906-828-1581 Fax 906-828-1583 Marquette 307 S* Front St* Ste 120 Marquette MI 49855-4613 Tel 906-273-1661 Fax 906-273-1663. D. to obtain information from any federal government records regarding me in connection with my claim or problem* Agency Signature Date / Name First Home Telephone Work Telephone Date of Birth / 2012 Last Social Security Number - - Address City State Zip County Claim Number if applicable Please describe your problem and the current status of your claim* This matter has been brought to the attention of former Congressman Bart Stupak Levin and/or Senator Debbie Stabenow. Please check all that apply. Senator Carl Mail or Fax this form Gaylord 810 S* Otsego Ave. Ste 105 Gaylord MI 49735-1780 Tel 989-448-8811 Fax 989-448-8858 Petoskey 200 Division St* Ste 178 Petoskey MI 49770-2465 Tel 231-348-0657 Fax 231-348-0653 Iron Mountain 500 S* Stephenson Ave. Please check all that apply. Senator Carl Mail or Fax this form Gaylord 810 S* Otsego Ave. Ste 105 Gaylord MI 49735-1780 Tel 989-448-8811 Fax 989-448-8858 Petoskey 200 Division St* Ste 178 Petoskey MI 49770-2465 Tel 231-348-0657 Fax 231-348-0653 Iron Mountain 500 S* Stephenson Ave. Ste 500 Tel 906-828-1581 Fax 906-828-1583 Marquette 307 S* Front St* Ste 120 Marquette MI 49855-4613 Tel 906-273-1661 Fax 906-273-1663. D. to obtain information from any federal government records regarding me in connection with my claim or problem* Agency Signature Date / Name First Home Telephone Work Telephone Date of Birth / 2012 Last Social Security Number - - Address City State Zip County Claim Number if applicable Please describe your problem and the current status of your claim* This matter has been brought to the attention of former Congressman Bart Stupak Levin and/or Senator Debbie Stabenow. Please check all that apply. Senator Carl Mail or Fax this form Gaylord 810 S* Otsego Ave. Ste 105 Gaylord MI 49735-1780 Tel 989-448-8811 Fax 989-448-8858 Petoskey 200 Division St* Ste 178 Petoskey MI 49770-2465 Tel 231-348-0657 Fax 231-348-0653 Iron Mountain 500 S* Stephenson Ave. Ste 500 Tel 906-828-1581 Fax 906-828-1583 Marquette 307 S* Front St* Ste 120 Marquette MI 49855-4613 Tel 906-273-1661 Fax 906-273-1663. .

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Keywords relevant to Privacy Act Release Form

  • Otsego
  • 2011
  • Stupak
  • 1974
  • Stabenow
  • applicable
  • TEL
  • Levin
  • AVE
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