United States Senate Seal

UNITED STATES SENATE

Senator Bernie Moreno

Great Seal of the State of Ohio
CONSENT FOR RELEASE OF INFORMATION

Please complete the following information (Please print). * indicates required fields.

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MILITARY or VETERANS ISSUES
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SOCIAL SECURITY ISSUES
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Appeals Council
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I am aware that provisions of the Privacy Act of 1974 (Public Law 93-579) requires written consent from the individual/constituent before Senator Moreno can obtain information from government agencies on your behalf and prohibits the release of information in my file without my approval. I hereby authorize the above-mentioned agency (agencies) to provide information regarding my case or claim to the Office of United States Senator Bernie Moreno. I certify, under penalty or perjury, that 1) I provided or authorized all of the information in this privacy release and any document submitted with it; 2) I reviewed and understand all of the information contained in my privacy release and submitted with it; and 3) all of this information is complete, true, and correct to be fully compliant with 6 CFR 5.21(d).

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Please Return Completed Form and Relevant Documents To:

Office of Senator Bernie Moreno

Attn: Constituent Services

Bricker Federal Building

200 North High Street, Room 618

Columbus, OH 43215

Phone: (614) 469-2083