United States House of Representatives Seal

UNITED STATES CONGRESS

Congressman Mark Upson

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

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MILITARY or VETERANS ISSUES
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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 Congressman Upson 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 Congressman Mark Upson. 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 Congressman Mark Upson

Attn: Constituent Services

Pennsylvania Office

456 Main Street, Suite 300

Pittsburgh, PA 15219

Phone: (877) 462-6523