Privacy Release Form

Authorization Form

* indicates information that you need to provide.

In accordance with the Privacy Act of 1974, I give Congressman Jim Langevin authority to act on my behalf.

Your Information
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Telephone
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Nature of Problem
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Use the Generate Request button to produce the document to authorize my office to help you. Then sign it and mail or fax it to the address shown on the document. Please include any other documents or material that you think would help my office help you.