Representing the 4th District of Connecticut

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Privacy Act Waiver

If you are seeking assistance and would like my staff to begin working on a concern or problem for you, the first step is filling out a Privacy Act Waiver.  This simply grants my office permission to begin working on your behalf.

Please print out the form below, either in English or in Spanish, and return it to my office by mailing or faxing it to us.  The office addresses and fax numbers are on the form.

Si necesita ayuda con una agencia federal y desea que mi oficina interfiera, el primer paso es llenar nuestro “Privacy Act Waiver”. Este formulario simplemente nos da su permiso para poder contactar a la agencia correspondiente.  

Por favor imprima y llene el formulario en ingles, o en español y devuélvalo a mi oficina a la dirección escrita en el formulario.