Written Authorization Under the Provisions of the Privacy Act of 1974

Rep. Royce's Written Authorization Under the Provisions of the Privacy Act of 1974

Please print the form, fill it out, sign it, and fax or mail it to Congressman Royce

305 N. Harbor Blvd., Suite 300

Fullerton, CA 92832

Fax: (714) 992-1668 Phone: (714) 992-8081 or (562) 220-2411

Date:

Dear Congressman Royce,

I would like to request assistance with the following problem I am having with the agency listed below.

In keeping with the restrictions of the Privacy Act of 1974, I am authorizing you and/or your staff to request information on me, which would be required in your investigation of the matter, outlined below.

Agency Name: U.S. Citizenship and Immigration Services (USCIS)

Name:

Address:

City:

State: CA Zip:

Daytime Phone:

Cell or other Phone:

Alien Registration Number:

The Form That Was Filed With USCIS:

Date Filed:

Date of Birth:

Briefly explain the nature of your complaint or concern and attach copies of any document you may have:

__________________________________________________

Signature